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A PRACTICAL TREATISE 



DISEASES OF THE TESTIS, 



AND OF TH£ 



SPEEMATIO CORD AND SCROTUM. 

CDitl) SUustrations. 
BY T.'b. curling, 

LECTURER ON SURGERY AND ASSISTANT SURGEON TO THE LONDON HOSPITAL, 
SURGEON TO THE JEWS' HOSPITAL, ETC. 

EDITED BY 

P. B. GODDARD, M.D., M.A.P.S., M.A.N.S., 

DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 



PHILADELPHIA: 

CAREY AND HART. 

1843. 



l^ 






I. 



■^^' 






Entered, according to an Act of Congi'ess, in the year 1843, 

By Carey and Hart, 

In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



// - 



C. SHERMAN, PRINTER. 



Amber's Dcbication. 



TO 



SIE BENJAMIN C. BRODIE, BART. F.E.S. 



SERJEANT SURGEON TO THE QUEEN, 



ETC. ETC. ETC. 



Dear Sir, 

The distinguished position that you have attained in 
our profession induces me to dedicate to you the following 
work, on a class of diseases the pathology and treatment of 
which you have successfully laboured to improve ; and in 
avaihng myself of the permission you have kindly granted 
me, I gladly embrace the opportunity of expressing my 
unfeigned respect for your high professional character, and 
the grateful sense I entertain of the many obligations you 
have conferred upon me. 

I am, dear Sir, 

Yours faithfully, 

T. B. Curling. 

37 New Broad Street, City, 
May 15, 1843. 



AUTHOR'S PREFACE. 

My attention having been directed in the year 1835 to the 
subject of the Morbid Anatomy of the Testis, I have since 
lost no opportunity of studying the pathological changes 
to which this organ is liable. My inquiries have been much 
facilitated by a connexion formed very early in professional 
life with a large hospital and with a dispensary, which have 
supplied me with abundant means of acquiring a practical 
knowledge of the diseases of this important organ. The 
result of these investigations having furnished facts which 
appear of some interest and value in relation to certain 
affections of the testis but imperfectly understood, and to the 
treatment generally of the disorders of this part, I have ven- 
tured to submit them to the consideration of my professional 
brethren. In arranging the materials for publication I 
have endeavoured to give a tolerably complete view of the 
different diseases of the testis and of the spermatic cord 
and scrotum, which I have described principally from my 
own observations. I have at the same time availed myself 
of the labours of my predecessors ; by which, it is hoped, I 
have not only added a good deal to the value of the work, 
but have also been able to correct and modify my own 
views concerning many of the subjects treated of. 

I was unwilling to overload a work which has somewhat 



VI PREFACE. 

exceeded the limits desired, with elementary matter to be 
found in most anatomical treatises ; but as ray researches 
on the structure of the testis have led me to describe cer- 
tain parts rather differently from other anatomists, and have 
enabled me to throw some light on the interesting subject 
of the descent of the testis, I have prefixed a concise, but 
it is hoped sufficiently minute account, of the anatomy of 
the parts in the adult and fcetal states, which, comprising, 
as it does, the most recent information on this subject, will 
probably be acceptable to my younger readers. 

In conclusion, I have to acknowledge the kind assistance 
which I have received in the progress of this work from 
several friends. To Mr. Bransby Cooper I am indebted 
for liberally permitting me to have engravings made from 
some of the preparations in the valuable collection fornied 
by the late Sir Astley Cooper; to my colleagues Mr. Luke, 
Mr. Hamilton, and Mr. Adams, for the particulars of 
several interesting cases which have occurred at the Lon- 
don Hospital ; and to Mr. John Quekett and Dr. Letheby 
for aid in my microscopical inquiries. In justice to a 
talented artist, it is right to state that the wood-cuts by 
which the work is illustrated were, with a few exceptions, 
executed by Mr. Bagg. 



PKEFACE OF THE AMERICAN EDITOR. 

A GOOD monograph on the diseases of the testicle has been 
for a long time a desideratum. Sir Astley Cooper's work 
on the testis in a great measure filled up the vacancy, 
but it still left something to be desired, and at the same 
time, from its size and consequent high price, was placed 
beyond the reach of the great body of the profession. The 
present work is entirely free from both these objections ; 
and having been carefully revised, and several additions 
made, it is hoped that its repubUcation in this country will 
meet the hearty approbation of the profession. 

The wood-cuts in this edition were executed by Mr. R. 
S. Gilbert, — and we owe our thanks both to him and the 
printer, Mr. C. Sherman, for the highly creditable manner 
in which their work has been executed. 



CONTENTS. 



PART I. 

ANATOMY OF THE SCROTUM AND TESTIS. 

The scrotum -------28 

Superficial or external spermatic fascia - - 28 

Cremaster muscle ------ 28 

Cases of voluntary power over its actions - - 31 

The testis - 32 

1. The protective parts or tunics - . _ 33 

Tunica vaginalis - - - - - 33 

Tunica albuginea - _ _ - 36 

2. The glandular or secreting structure - - - 38 

Tubuli seminiferi ----- 39 

Rete testis ------ 43 

3. The excretory parts ----- 44 

Epididymis ------ 44 

Vasculum aberrans . - - _ 47 

Vas deferens ------ 49 

4. The vessels and nerves - - - - 50 

Spermatic vessels - - - - - 50 

Absorbents ----- 53 

Nerves ------ 53 

The testis in the foetus, and its descent into the scrotum 54 

Gubernaculum - - - - - 54 

Causes of the descent of the testis - - 60 

Spermatic fluid - - - - - . - 61 

The functions of the testis . - - - 64 

Effects of castration on the economy - - - 69 
2 



X CONTENTS. 

PART II. 

DISEASES OF THE TESTIS. 

CHAPTER I. 

Congenital imperfections and malformations - - 74 

Sect. I. Numerical excesses and defects - - - 74 

Supernumerary testis - - - - - 74 

Supposed cases of - - - - - 75 

Bodies mistaken for additional testes - - - 76 

Absence of one or both testes _ . . 77 

Cases of - - - - - - - 77 

Union of the testes ----- 82 

Sect. 11. Deficiencies and imperfections of the vas deferens - 83 
The origin of these defects explained - - 86 
Their influence on the evolution and subsequent condi- 
tion of the testis ----- 88 

Experiments on the vasa deferentia of animals - - 89 

Sect. 111. Imperfect descent of the testis - - - 92 

Causes of ------ 94 

The condition of the undescended testis - - 98 
Liability of the gland to injury and disease when retained 

in the groin ----- 104 

Tendency to produce rupture - - - - 106 

Diagnosis in cases of imperfect descent of the testis 113 

Bubonocele - • - - - - 113 

Descent of the testis into the perineum - - 117 

CHAPTER n. 

Atrophy of the testis ----- 118 

Sect. I. Arrest of the developement of the testis - 119 

Cases of ------ 120 

Connected with defective organization of the brain - 122 

Sect II. Wasting of the testis - - - - 123 

Weight of the testis in health and disease - - 124 

Changes in the form and structure of atrophied testes - 125 

Deposition of fat in the testis - - - 125 

Causes of wasting of the testis - - - - 126 

Impeded circulation ----- 127 

Pressure ------ 127 

Want of exercise - - - = - 128 

Loss of nervous influence . . - - 130 



I 



CONTENTS. XI 

Inflammation ------ 131 

Use of iodine ----- 132 

Elephantiasis ------ 132 

Injuries of the head - - - _ 133 

Cases of wasting of the testis from - _ . 133 



CHAPTER III. 

Injuries of the testis ----- 137 

Sect. I. Contusions and incised and punctured wounds - 137 

Contusions ------ 137 

Squeezing- the testis a mode of emasculating - - 139 

Punctured and incised wounds - - - 139 

Sect. 11. Self-castration ----- 140 

Cases of - - - - - - 141 

CHAPTER IV. 

Hydrocele ------- 145 

Acute hydrocele, or inflammation of the tunica vaginalis 145 

Pathological changes from - - - - 145 

Table of the different varieties and complications of hy- 
drocele -,---- 150 

Sect. I. Simple hydrocele of the testis - - - 151 
Characters of the fluid accumulated in the tunica vagi- 
nalis -.-.--. 151 
Situation of the testis - - - - 153 

Multilocular hydrocele - - - - - 154 

Pouch formed by dilatation of the cul-de-sac between the 

testis and epididymis ----- 154 

Changes in the sac ----- 155 

Period of life at which hydrocele occurs - - 156 

Side more frequently affected - - - 153 

Causes of hydrocele ----- 159 

Symptoms ------ 161 

Modifications in - _ _ - - 162 
Hydrocele sometimes varies in size, is smaller at night 

and increases during the day - - _ 165 

Diagnosis ------ 165 

Scrotal hernia - - - - - -166 

Malignant disease ----- 167 

Treatment - - - - - - 168 

Spontaneous disappearance of hydrocele - - 169 



XI 1 CONTENTS. 

Treatment of hydrocele in infants . - - 170 

Cure of hydrocele ia the adult by external remedies 171 

Cure after rupture of the sac - - - . 173 

Palliative treatment by operation - - - 174 

Operation of tapping - _ _ _ - 174 

Acupuncture _ _ _ - - 178 

Radical treatment of hydrocele by operation - - 182 

Incision ...... 182 

Excision - - - - - - 184 

Caustic 186 

Tent 188 

Seton 188 

Injection --_..- 191 

Mode of operating ----- 192 

Fluids injected - - - - - - 193 

After-treatment ----- 195 

Hydroceles not to be injected when recent or of large 

size .-.--. 197 

Risks of the operation ----- 199 

Failures 201 

Treatment of double hydrocele - - - - 201 

Iodine injections ----- 202 

Concluding remarks on the treatment of hydrocele - 205 

Sect. II. Congenital hydrocele - - - - 207 

Mode of formation ----- 207 

Symptoms ------ 208 

Diagnosis ------ 209 

Treatment --.--- 209 

Sect. III. Encysted hydrocele of the testis - - - 211 

Developed in three situations - - - 211 

Encysted hydrocele of the epididymis - - - 212 

Of the tunica albuginea - - - - 214 

Of the tunica vaginalis - - - - 216 

Symptoms ------ 217 

Diagnosis - - - - - - 218 

Treatment ------ 218 

Severe effects of puncturing the cysts when numerous - 221 

Sect. IV. Diffused hydrocele of the spermatic cord - 223 

Structural changes ----- 223 

Symptoms ------ 225 

Diagnosis ------ 227 

Omental hernia ----- 227 



CONTENTS. Xlll 

Encysted hydrocele of the cord - - - - 228 

Treatment ------ 229 

Sect. V, Encysted hydrocele of the spermatic cord - - 230 

Mode of formation ----- 230 

Symptoms ------ 234 

Diagnosis ------ 234 

Simple hydrocele ----- 234 

Hernia 234 

Treatment ------ 236 

Incision ------ 237 

Seton ------- 238 

Operations apt to produce diffuse inflammation of the 

cord - - - - - - - 239 

Sect. VI. Complications of hydrocele - - - 239 
Simple hydrocele combined with encysted hydrocele of 

the testis ------ 240 

Simple hydrocele combined with encysted hydrocele of 

the spermatic cord _ - . _ 241 
Simple hydrocele combined with diffused hydrocele of 

the spermatic cord - - - , 242 

Oscheo-hydrocele ----- 243 

Simple hydrocele combined with inguinal hernia - 243 
Encysted hydrocele of the cord combined with inguinal 

hernia ------ 246 

Sect. VII. Hydrocele of the hernial sac - - . 249 

Mode of formation ----- 249 

Diagnosis ------ 252 

Treatment - - - - - - 253 

Spurious hydrocele of the hernial sac - - - 256 

Sect. VIII. Hydrocele in the female - - - 260 

Diffused hydrocele of the round ligament - - 261 

Hydrocele of the canal of Nuck - - - 261 

Encysted hydrocele of the round ligament - - 261 

CHAPTER V. 

HEMATOCELE ------- 262 

Sect. I. Hsematocele of the testis - - - 262 

Extravasation of blood into the healthy tunica vaginalis 262 

Extravasation in combination with hydrocele - 263 

Changes which the blood undergoes - - - 264 

Changes in the sac - - - - - 265 

Position of the testis ----- 266 



XIV CONTENTS. 

Effects of the extravasation on the testis - - 267 

Symptoms ------ 269 

Diagnosis ------ 270 

Treatment ------ 271 

If the extravasation be small, an operation to be avoided 271 

Operation of incision - _ . _ 272 

Effects often severe ----- 273 

Sect, XL Heematocele of the spermatic cord - - 275 

Diffused 275 

Encysted ------ 275 

Symptoms ------ 277 

Cases recorded by Pott - - - - 277 

CHAPTER VI. 

Orchitis --__--. 280 

Sect. I. Acute orchitis ----- 280 

' Anatomical characters ----- 280 
Liability of the epididymis to disease in consecutive 

orchitis - - - - - - 282 

Suppuration in the testis - - - - 282 

Permanent effects of orchitis . - - - 285 

Causes of orchitis ----- 287 

Its occurrence in cases of mumps - - . 288 

In gonorrhoea ----- 289 

The doctrine of metastasis in gonorrhcEal orchitis - 290 
Effects of cubebs, copaiba, and injections, in giving rise 

to it 294 

Side more commonly affected - - - - 296 

Symptoms ------ 297 

Rheumatic orchitis ----- 298 

Acute orchitis in infants - - - - 299 

Cases of - - - - - - 299 

Diagnosis ------ 303 

Strangulated scrotal hernia - - - - 303 

Treatment ------ 304 

Local applications ----- 305 

Tartar emetic ----- 306 

Mercury - - - - - - 307 

Blood-letting . - . . - 307 

Compression by strapping - . _ - 309 
Old practice of inoculating the urethra in gonorrhceal 

orchitis -.-._- 313 



CONTENTS. XV 

Mr. Ramsden's views of the connexion between the ure- 
thra and testis - - - - - 313 

Sect. II. Chronic orchitis - - - - - 316 

Anatomical characters - - - - 316 

Seat of the yellow deposit _ - - - 317 

Case in illusiration ■■---- 318 

Granular swelling, or hernia testis . _ - 323 

Mode of formation ----- 323 

Effects of chronic orchitis on the testis - - - 324 

Causes ------ 326 

Symptoms - - - - - - 328 

Suppuration ------ 331 

Spermatic fistula ----- 331 

Obstinate character of cases of pus in the testis - 332 

Chronic orchitis in infants - - - - 334 

Diagnosis ------ 335 

Encephaloid cancer ----- 335 

Hsematocele ----- 336 

Treatment - - - - - - 336 

Mercury . . - . - - 336 

Compression ------ 337 

Constitutional remedies - - - - 338 

Case in illustration of the treatment - - - 340 

Treatment of hernia testis - - - - 343 

Excision of the fungus objected to - - - 344 

Sect. Ill, Syphilitic orchitis - - - - 347 

Treatment - - - - - , - 348 

CHAPTER VII. 

Tubercular disease of the testis - - - - 349 

Anatomical characters - _ - - 350 

Original seat of the deposit _ - - - 352 

Spontaneous cure ----- 353 

Cretaceous deposit an indication of cure - - 353 

Symptoms ------ 355 

Softening and suppuration of the tubercular matter - 355 

Suppuration of the strumous testis in children - 356 

Cases in illustration ----- 356 

Diagnosis ------ 358 

Chronic orchitis ------ 358 

Malignant disease ----- 359 

Treatment ...--- 359 



XVI , CONTENTS. 

Constitutional ------ 359 

Local - - - - - - 360 

CHAPTER VIII. 

Carcinoma OF THE TESTIS - - - - - 361 

Sect. I. Schirrus of the testis - - - - 362 

Anatomical characters ----- 362 

Symptoms ------ 362 

Diagnosis - - - - - - 363 

Treatment 363 

Sect. II. Encephaloid cancer of the testis - - - 364 

Anatomical characters - - - - 364 

Effects of the disease on the spermatic cord, lumbar glands, 

and distant parts ----- 367 

Period of life at which it occurs - - . 368 

Symptoms ------ 369 

Diagnosis ------ 373 

Hydrocele ------ 373 

Hsematocele ------ 373 

Encephaloid cancer - - - - 374 

Cystic sarcoma ------ 374 

Chronic orchitis ----- 375 

Case illustrative of the difficulties of the diagnosis - 37.5 

Treatment ------ 378 

Sect. III. Carcinoma of the tunica vaginalis - - - 382 

Cases ------ 382 

Sect. IV. Colloid cancer and melanosis of the testis - - 385 

CHAPTER IX. 

Cystic disease of the testis - - - - 386 

Anatomical characters - - - - - 386 

Symptoms - - - - - - 390 

Diagnosis ------ 390 

Hydrocele ------ 390 

Encephaloid cancer ----- 390 

Treatment ------ 391 

CHAPTER X. 

Fibrous transformation of the testis - - - 392 

CHAPTER XI. 

Ossific deposits in the testis - . - - 394 



I 



J 



CONTEiNTS. XVii 

CHAPTER XII. 

Loose bodies in the tunica vaginalis - - - 395 

Their mode of origin - - - . 397 

CHAPTER Xm. 

Spermatocele --.-.- 399 

CHAPTER XIV. 

FffiTAL REMAINS IN THE TESTIS - - - - 399 

CHAPTER XV. 

EnTOZOA IN THE TESTIS . . . - . 400 

CHAPTER XVI. 

Nervous affections of the testis . - - 401 

Sect. I. Irritable testis .--.,_ 401 

Symptoms ------ 401 

Causes 403 

Treatment ------ 403 

Case - 404 

Castration objected to - - - - 406 

Case in illustration - - - - - 406 

Sect. II. Neuralgia of the testis - - - - 406 

Symptoms ------ 406 

Causes ------ 408 

Treatment - - - - - - 409 

Castration - - - - - - 411 

Failures of ------ 412 

Sir A. Cooper's successful cases of castration examined 413 

The operation proper only in certain cases - - 416 

CHAPTER XVII. 

Sympathetic and functional disorders of the testis - 417 

Impotency from injuries of the head - - 418 

Cases of -....- 418 

Constitutional indifference to the sex - - 421 

Relative impotency ----- 422 

Impotency from want of self-confidence - - 423 
3 



XVlll 



CONTENTS. 



Case in illustration, and treatment suggested by Hunter 423 
Effects of diseases of the testis on the functions of the 

gland .-.-.-- 425 
Question of the power of procreation for a certain period 

after castration _ _ _ - - 426 

Cases in illustration ----- 426 
Effects of apoplexy and paraplegia on the functions of the 

testis ------- 429 

Curious case in illustration - - - - 429 

Effects of chronic diseases on the fimctions of the testis 481 

Phthisis- .-...- 431 

Indigestion ------ 432 

Diseases of the kidneys ----- 433 

Abuse of the sexual organs a frequent cause of impotency 433 

Also of affections of the digestive organs and kidneys - 435 

Involuntary seminal emissions . _ - 435 

Symptoms of this complaint - - - - 435 

Causes 436 

State of the spermatic secretion - - . 437 
Morbid changes in the urethra, prostate, and vesiculae 438 
Their effects on the mind of the patient and on the secre- 
tions of the testes ----- 440 

Difficulty of detecting the disease - - - 442 

Treatment -...-. 442 

Application of the nitrate of silver to the urethra - 442 

Lallemand's caustic instrument described - - 444 

Constitutional treatment . - - - 446 

Propriety of marriage in these cases . - - 447 

Castration objected to - - - - 448 

Solitary abuse in infancy - - - - 449 

Aphrodisiacs - - - - - 449 

Cantharides ------ 450 

Phosphorus - - - - - - 450 

Ergot of rye - - . - - 451 

Indian hemp - . _ . _ 451 



CHAPTER XVIII. 
Castration - - . . - 

Diseases of the testis requiring the operation 
Mode of operating 
Retraction of the spermatic cord 
Secondary hspmorrhage - - - 



452 
453 
453 
457 
459 



CONTENTS. XIX 

Castration in cases of disease of the testis complicated 

with hernia ------ 460 

Extirpation of a diseased testis retained in the groin 461 

Cases of 462 

Slig-ht fatality of castration - - - - 463 
Maunoir's operation of tying the spermatic artery for the 

cure of sarcocele ----- 463 



PART III. 

DISEASES OF THE SPERMATIC CORD. 

CHAPTER I. 

Varicocele - - - - - - - 465. 

Anatomical condition of the spermatic veins - 465 

Side more frequently affected - - - - 466 

Relation between varicocele and varices in other parts 467 

Causes of varicocele ----- 467 

Anatomical ------ 467 

Occasional --._-- 469 

Effects of this disease on the testis - - - 470 

Age at which it occurs ----- 471 

Symptoms - - - - - - 471 

Aggravated after sexual connexion . - - 473 

Pain sometimes severe, and of a neuralgic character 474 
Cases of varicose veins combined with neuralgia in other 

parts ------ 474 

Acute varicocele - - - - - 475 

Remarkable cases of, recorded by Pott - - 476 

Diagnosis ------ 479 

Hernia ------ 479 

Palliative treatment of varicocele - . - 480 

Mr. Wormald's plan of supporting the testis - 481 

Radical treatment of varicocele - - - 482 

Excision of the scrotum . - - - 482 

Lehmann's operation for shortening the scrotum - 486 

Operations on the veins - *. - - 487 

Division of the vessels ----- 487 

Ligature ------ 489 

Dangers of ----- - 489 

Davat's plan * .... 489 



XX CO^TEM'S. 

Ricord's - 490 

Mr. Luke's 492 

Case 492 

Compression of the veins - . - - 494 

Application of Breschet's forceps - _ _ 494 
Local compression to take off the hydrostatic pressure of 

the blood ----_. 495 

Principle of this mode of treatment - - - 495 
Case cured by the application of Evans's patent lever 

truss ..-..- 497 

Excision of the veins - - . . _ 499 

Concluding remarks on the treatment of varicocele 500 

CHAPTER IL 

Adipose tumours of the cord - - _ . 503 

Liable to be mistaken for hernia - - - 504 

Case in illustration ----- 505 

Ossific tumours in the cord - - - - 506 

CHAPTER m. 

Spasm of the cremaster muscle - . - - 506 

Causes ---.,. 506 

Case of spasm arising from injury - - - 507 



PART IV. 

DISEASES OF THE SCROTUM* 

CHAPTER L 

Lnjuries of the scrotum ----- 509 

Contusions - ... _ . . 509 

Lacerations ----- . 529 

Case of injury by caustic potass - - - - 511 

CHAPTER n. 
Prurigo scroti - - - _. _ ^n 

Treatment ----.= 512 

CHAPTER m. 
Varicose veins of the scrotuim - - - . 514 



CONTEJNTS. 



XXI 



CHAPTER IV. 



Pneumatocele 



515 



CHAPTER V. 

CEdema scroti - - - - - 

Symptoms - - - - - 

Causes - - - - - 

Diagnosis . . - _ - 

Case of cedema confined to one side of the scrotum 
Treatment . . - . , 

CHAPTER VI. 

Diffuse inflammation of the scrotum - 

Mild form of 

Cases - - - - - 

Severe form . - - - - 

Case - - - = - 

Diagnosis . - - - - 

Treatment - - - - - 



515 
516 
517 

517 

518 
519 



520 
520 
521 
522 
522 
523 
524 



CHAPTER Vn. 



Mortification of the scrotum - 
From the effects of cold 
Case . . - 

Treatment 



525 
526 
526 
526 



CHAPTER Vni. 

Elephantiasis scroti - - - - - 

Anatomical characters - - - - - 

Countries in which it occurs ... 

Nature of the disease - - - - - 

Causes ------ 

Symptoms -._.-_ 

Liable to be complicated with hernia, and with hydro- 
cele ------ 

Immense size of many of these tumours 
Effects of the disease on the general health 



Treatment - 
Excision of the tumours 



523 
528 
530 
531 
531 
532 

535 
535 
536 
538 
538 
539 



XXll 



CONTENTS. 



Remarkable cases of - - - 

Dangers of haemorrhage in the operation 
Fatal cases from loss of blood 
Propriety of saving the genital organs •■ 
Delpech's case, in which they were preserved 



540 
540 
540 
540 
541 



CHAPTER IX. 

Hypertrophy of the scrotum - - - - 

CHAPTER X. 

Cancer scroti -----. 

Its mode of origin . - - - - 

Soot-wart -»---- 

Progress of the disease - - - - - 

Ulcerative stage . . - - - 

Nature of the soot- wart - - - - - 

Remarkable case of cauliflower excrescence 
Conical excrescences and elongated processes - 
Anatomical characters of the morbid tissue - 
Soot the exciting cause of the disease - - - 

Sir J. Earle's case of the gardener with the same disease 

on the hand - . - _ _ 

Scrotum far more liable to chimney-sweeper's cancer 

than the skin of other parts - . - - 

May be produced by other irritating substances besides 

soot ------ 

Hereditary predisposition to the disease 
Cases of - - " - - - 

Age at which cancer scroti occurs - - . 

Seeds of the disease sown in early life germinate at a 

remote period - - _ . _ 

Illustrated by the case of a sailor affected with cancer 

scroti ------ 

Slight tendency of the disease to affect the lymphatic 

glands ------ 

Chimney-sweeper's cancer almost peculiar to Great 

Britain ----.. 

Now a rare disease even in this country 

Diagnosis ------- 

Treatment ------ 

Excision of the morbid scrotum - - - - 



545 



546 
546 
546 
546 
547 
548 
548 
549 
549 
551 

551 

552 

554 
554 
554 
554 

555 

555 

556 

557 
.558 
558 
559 
559 



CONTENTS. XXIU 

May be performed when the glands in the groin are en- 
larged ..---. 560 
Reappearance of the disease after operation - - 560 
To be treated on different principles from cancer in other 

parts, and a repetition of the operation advised - 561 

Case in illustration ----- 562 

Treatment when the inguinal glands are ulcerated - 562 

CHAPTER XL 
Melanosis of the scrotum . . . . 553 

Case -.....- 563 

CHAPTER XII. 
Adipose tumours of the scrotum . . - 564 

CHAPTER Xni. 
Fibrous tumours of the scrotum ... - 565 

Remarkable stony tumour excised by Dr. Mott - 565 

APPENDIX. 

Recent discovery by Mr. Listen of spermatozoa in the fluid of 
an encysted hydrocele of the testis - - - . 567 

The author's observations, and explanation of the occurrence 

of these bodies in this case ----- 568 



A PEACTICAL TREATISE 



ON THE 



DISEASES OE THE TESTIS, 



ETC. 



PAET I. 
ANATOMY OF THE SCROTUM AND TESTIS. 

THE SCROTUM. 

The scrotum is a pouch, formed of the common 
integuments, for the reception of the testicles. It 
is evenly divided externally into two halves by a 
prominent ridge, a continuation of the raphe, from 
the under part of the penis to the perineum. The 
skin of the scrotum is thin, like that of the penis 
and eyelids, and browner than in most other parts ; 
in some individuals a colouring matter, similar to 
that which occurs in the skin of the negro, may be 
perceived beneath the cuticle. It is abundantly 
supplied with sebaceous follicles ; and short hairs, 
obliquely inserted, are thinly scattered over its sur- 
face. It is very loose and extensible, a fact which 
is often witnessed in connexion with scrotal hernia, 
and various chronic enlargements of the testis. 
When corrugated it is thrown into numerous folds 
or rugae, running at right angles with the raphe, 

4 



26 THE SCROTUM. 

which give it a wrinkled appearance and greatly 
diminish its size. 

Immediately beneath the skin, there is a thin 
layer of contractile tissue of a reddish-gray colour, 
termed the dartos, which is so intimately connected 
with the inner surface of the common integument, 
that their separation is difficult, and the one follows 
the movements of the other. The dartos has re- 
cently been carefully examined by Mr. Bowman, 
who considers it to be muscular, and composed 
of " unstriped elementary fibres," the presence of 
which, in consequence of the abundant admixture 
of areolar tissue, has not hitherto been clearly re- 
cognised.^ 

The movements of the scrotum, by the action 
of the dartos, are conspicuous enough ; they are 
gradual, vermicular, and involuntary. Mr. Bow- 
man states, that since satisfying himself of the 
existence of the unstriped fibre in the dartos, he 
has on many occasions detected a very decisive 
peristaltic action, advancing from one side of the 
scrotum to the other, and continued for a consider- 
able period. This I have also myself observed. 
Contraction is excited by cold, and takes place 
under the influence of fright and during the vene- 
real orgasm : relaxation is caused by heat : galvan- 
ism produces no eflfect. 

Directly beneath the dartos, between it and the 
cremaster muscle, a large quantity of cellular tissue 
is found, remarkable for its looseness and not con- 

* Cyclopsedia of Anatomy and Physiology, art. Muscle, p. 518. 



THE SCROTUM. 27 

taining adipose matter, characters highly favourable 
to the free motions of the testicles, which can be 
drawn up towards the inguinal ring in such a way 
as to leave the scrotum empty. In the median line 
opposite the raphe, the cellular tissue is close and 
condensed, and forms the septum scroti. The 
septum, however, is permeable, as is shown by 
inflation and in oedema, in which air and fluid are 
found to pass from one side to the other. 

The arteries of the scrotum arise on each side 
from three sources: the external pudic, the internal 
pudic, and the epigastric. The superior branch of 
the external pudic sends vessels to the front and 
upper part of the scrotum, and the inferior branch 
supplies its lateral portion. The perineal artery 
passes upon the septum scroti, and sends olT nume- 
rous branches, which are tortuous, and form a 
complete network in the dartos. The scrotum also 
receives a few vessels from the branches of the 
epigastric sent to the creraaster muscle. All these 
vessels freely communicate with each other, and 
with the corresponding vessels on the opposite side. 
The veins of the scrotum are numerous, tortuous, 
and comparatively of considerable size, and take 
the course of their corresponding arteries. The 
absorbent vessels are large and numerous, and join 
the inguinal glands. The nerves of the scrotum 
are derived from three sources: 1, from the ileo- 
scrotal nerve which arises from the first lumbar 
nerve ; 2, from the external pudic or spermatic, a 
branch of the second lumbar nerve ; and, 3, from 
the perineal nerve. 



28 THE SCROTUM. 

In persons in health and vigour, the scrotum is 
corrugated and contracted, and contributes to sup- 
port and brace the testicles ; but in those of feeble 
frame, in a state of debility and ill-health, and in 
old age, it is pendulous and lax, and suffers the 
testicles to droop. The testicles being well braced 
by the scrotum is a sign, therefore, of good health 
and bodily strength, as well as of sexual vigour, a 
circumstance which did not escape the notice of 
the ancient sculptors. 

The scrotum, including the dartos, is distinctly 
developed in the foetus previous to the descent of 
the testis. It is a part, however, dependent on the 
testicles ; and in cases where these organs have not 
descended the pouch is wanting, there being only 
a broad raphe running from the perineum to the 
penis, with distinct rugae passing at right angles 
to it on either side. When one testicle only has 
descended, the scrotum is slightly developed on the 
opposite or empty side. 

Superficial or External Spermatic Fascia. — Be- 
neath the loose cellular tissue of the scrotum is 
situated a delicate layer of fascia, which is con- 
tinuous with the superficial fascia of the lower part 
of the abdominal parietes, and, descending so as to 
form a sheath to the spermatic cord and an envelope 
to the testis, runs on to be continued behind into 
the superficial fascia of the perineum. This fascia 
is usually very thick and distinct in cases of large 
and old scrotal hernia. 

Cremaster Muscle. — Directly beneath the super- 
ficial fascia is found the cremaster muscle, or, as it 



THE SCROTUM. 



29 



has been appropriately termed by Mr. Hunter, the 
musculus testis. This muscle is usually considered 
and described as a part or process of the obliquus 
internus ahdominis. It has, however, separate 




attachments ; and its office and connexions are so 
entirely distinct, that it ought to be regarded as an 
independent muscle. The cremaster has two fixed 
points of attachment ; one external and one internal. 
The external, which is generally, but not always, 
the larger, consists of a number of fasciculi of mus- 
cular fibres, which take their origin from Poupart's 



30 THE SCROTUM. 

ligament within the inguinal canal. The fasciculi 
which arise at the upper part of the canal are 
blended with the fibres of the internal oblique, and 
often also with those of the transversalis ; but the 
fibres properly belonging to the cremaster are 
usually separated from these muscles by intervening 
cellular tissue. The internal attachment of this 
muscle is to the os pubis and sheath of the rectus 
muscle by fasciculi partly tendinous and partly 
muscular. From these two attachments flat and 
slender bands of thin and very pale muscular fibres 
descend at the sides, in front, and often at the back 
of the cord, and form a successive series of curves 
or loops of various sizes and lengths, which increase 
as they descend. The lower loops spread out, and 
are intimately connected with a thin aponeurotic or 
fibro'tendinous structure, which invests the tunica 
vaginalis, and is attached to the posterior edge 
of the testis and lower part of the vas deferens. 
This muscle is abundantly supplied with nerves, 
branches of the external spermatic. 

The developement of the cremaster muscle varies 
considerably in diiferent individuals and at difierent 
ages. It is very distinct in adults of muscular 
frame, and remarkably so in certain cases of hernia 
and hydrocele, when its fibres are hypertrophied. 
Previous to puberty it is small and indistinct ; and 
in persons much emaciated by disease or advanced 
in age its arches are so thin and pale as scarcely to 
be discerned. The actions of the cremaster, which, 
with a few exceptions, are involuntary, appear to 
be those of giving a tonic support to the testicles, 



i 



THE SCROTUM. 31 

retracting them to the abdominal rings, and com- 
pressing them during the sexual act. In some 
instances in boys before the approach of puberty, 
this muscle has been capable of drawing the gland 
up into the inguinal canal. Persons are occa- 
sionally met with who possess a voluntary power 
over its actions in various degrees of perfection. 
Some are able to elevate the testicle on one side but 
not on the other ; whilst others can retract both 
testicles to the abdominal ring, and retain them 
there at will. A very remarkable instance of the cre- 
master muscle being completely under the influence 
of volition, is recorded by Mr. A. C. Hutchinson. 
It was the case of a sailor who availed himself of 
it to cause tumours in the groins which simulated 
hernia, in order to avoid impressment in the king's 
service. On being detected he displayed several 
remarkable feats of the power he possessed over 
these organs. He pulled both testes from the 
bottom of the scrotum up to the external abdominal 
rings with considerable force, and again dropped 
them into their proper places with singular facility. 
He then pulled up one testis, and, after some pause, 
the other followed, as the word of command was 
given ; he then let them both drop into the scrotum 
simultaneously. He also pulled one gradually up, 
whilst the other was as gently descending ; and he 
repeated this latter experiment as rapidly as the 
eye could well follow the elevation and descent of 
the organs.* 

^ Practical Observations in Surgery, 2d edit. p. 186. 



t 



32 THE TESTIS. 

THE TESTIS. 

The testes are universally known as the glands 
by which the semen or spermatic fluid is secreted : 
contained within the scrotum, they are suspended 
at a variable and unequal distance from the ab- 
dominal rings, one testis, generally the left, hanging 
a little lower than the other. This arrangement 
prevents any collision between these organs when 
the thighs are suddenly approximated ; one testicle 
slipping above the other, and thus eluding violence. 
In cases of transposition of the viscera and blood- 
vessels, it has been observed that the right testicle 
hangs lower than the left. 

The shape of the testis of an adult is that of an 
oval with flattened sides. The organ has two ex- 
tremities, an antero-superior, and a postero-infe- 
rior ; two edges, an antero-inferior, and a postero- 
superior ; and two lateral surfaces. Its position in 
relation to the body is rather oblique, its long axis 
or antero-posterior diameter passing from above 
downwards and a little inwards. Its edges and 
sides are convex. Its upper extremity is rounded 
and capped by the epididymis, which rises above 
the body of the gland like the crest on a helmet. 
The mean dimensions of the testis are one inch and 
three quarters in length, one inch and a quarter 
across or in breadth, and one inch in thickness or 
from side to side.* Meckel states its average weight 

* According to Cruveilhier, the testis measures two inches in length, 
one inch in breadth, and three lines in thickness. Sir A. Cooper makes 
its long diameter two inches, its transverse an inch and a half, and its 
lateral one inch and one eiffhth. 



THE TESTIS. 33 

to be four drachms, and Sir A. Cooper about an 
ounce. I have found the mean of these two esti- 
mates, viz. six drachms, to be the ordinary weight 
of the sound testis of a healthy adult. There are 
few organs subject to greater variations in size and 
weight than the testis, even in men of the same age 
and constitution. The testicles also of the same 
individual rarely agree, the volume and weight of 
the left testis being in general greater than those of 
the right. I weighed the testicles of six men, two 
of whom were killed by violence, and found the left 
gland heavier than the right in ^ve ; in neither of 
these instances, however, was the difference more 
than a drachm. The organ feels tense, compact, 
and slightly elastic. Its degree of consistence de- 
pends more on the tension of the tunica albuginea 
than on the proper substance of the gland, but it is 
a good deal influenced by the quantity of seminal 
fluid contained in the tubular structure, and its 
state of activity or rest ; the gland being tense and 
tumid when the ol'gan is exercised and the tubuli 
are distended, and soft and flaccid when they are 
empty and the gland inactive. 

The parts composing the testis may be described 
under four heads : — I. The protective parts or 
Tunics ; II. The proper glandular or secreting 
Structure ; III. The excretory Parts ; IV. The 
Vessels and Nerves. 

I. The Protective Parts or Tunics. 

The Tunica Vaginalis, — This is a delicate serous 
membrane in the form of a shut sac, which consists 

5 



34 THE TESTIS. 

of two portions ; an outer one, free and loose, and 
an inner, reflected, or testicular portion, which 
closely invests the gland. Sir A. Cooper designates 
the loose portion the tunica vaginalis reflexa. In 
accordance, however, with the analogies afforded 
by the other serous pouches, I have termed the tes- 
ticular the reflected portion of the membrane. In 
speaking, therefore, of the tunica vaginalis, without 
the addition of the term reflected or testicular, it 
will be understood that I mean to imply the outer 
and loose portion. The two portions are connected 
and continuous with each other. The outer one 
loosely invests the whole of the testis, except its 
posterior edge and inferior extremity, parts where 
it becomes attached to the gland. It is connected 
with the testis at about five lines from the lower 
extremity, and the junction of the two portions is 
marked by a white and rather irregular line. The 
uncovered portion of the testis corresponds to the 
original attachment of the gubernaculum. On the 
inner side of the gland the membrane, after invest- 
ing the lower part of the cord to a greater or less 
extent, is reflected to the epididymis just below its 
head, and to the posterior edge of the body of the 
testis, being there separated from the epididymis by 
the vas deferens and blood-vessels of the gland. 
On the outer side the membrane entirely covers and 
closely invests the epididymis, and forms a cul-de- 
sac, which isolates its middle from the posterior 
border of the testis, and in cases of hydrocele is 
often distended into a good-sized pouch. At the 
bottom of this sac the tunica vaginalis on the two 



I 



THE TESTIS. 35 

sides comes into close contact, and sometimes there 
is a communication at this spot between the two. 
The smooth and polished surface of the shut sac 
thus formed by the tunica vaginalis is lubricated by 
a halitus, which, when condensed, forms a serum, 
having the ordinary properties of the secretions of 
the other serous membranes. The office of this 
membrane is to facilitate the movements of the tes- 
tis, so as to enable it to elude pressure and escape 
violence. 

In some adult subjects the tunica vaginalis, which 
was originally a process from the serous lining of 
the abdomen, still retains its connexion with that 
cavity. When the communication is free, the sac 
is very liable to receive a protrusion of some of the 
contents of the abdomen, and become the seat of 
congenital hernia. Sometimes the communication 
continues through a contracted tubular canal, which, 
though too narrow to admit the transit of any of 
the viscera, is open to the passage of fluid. In 
other cases the obliteration is partial, one or more 
isolated serous sacs being left along the cord. It 
more often happens, however, that after the upper 
aperture of this process has closed, a considerable 
part of it below remains unobliterated, so that the 
tunica vaginalis extends for some distance upwards 
in front of the cord. Frequently, also, although 
the obliteration is complete, remains of the pro- 
longation may still be found in the form of a slender 
whitish filament, or fibro-cellular process, which is 
lost in the cellular tissue in the anterior part of the 



36 THE TESTIS. 

cord, but may sometimes be traced as far as the 
tunica vaginalis. 

A small body of an irregular shape and variable 
size, and of a pale red or pinkish hue, is commonly 
found attached either to the upper extremity of the 
testis, or at the angle where the tunica vaginalis 
passes from the body of the gland to the epididymis. 
It is composed of a duplicature of this membrane, 
containing some fine cellular tissue and a number 
of small vessels. I have seen this little body in the 
testis of the foetus v\^hilst in the abdomen ; and in 
early life it is often of proportionally larger size, 
and of a deeper red colour than in the adult. It is 
quite distinct from the pedunculated cysts often 
found attached to the head of the epididymis. This 
little appendage to the tunica vaginalis seems to 
correspond with, and to be a type of, the remark- 
able omental process attached to the superior part 
of the testis in the Rodentia and other animals. 
That it is an unimportant structure in the adult is 
shown by its being frequently wanting. 

Tunica Alhuginea or Tunica Propria is a dense, 
resisting, inelastic membrane, composed of fibrous 
tissue analogous to the sclerotic coat of the eye. 
It completely invests the body of the testis, but not 
the epididymis. - Its external surface is covered by 
the tunica vaginalis reflexa, to which it intimately 
adheres. This tunic is divisible into two layers, 
which can only be separated by a tedious dissection, 
but which in certain animals may be detached with- 
out difficulty. The branches of the spermatic artery 



THE TESTIS. 37 

and veins ramify in the substance of the tunica 
albuginea, in canals bearing in their arrangement 
some analogy to the sinuses of the dura mater ; 
which membrane the outer layer is supposed to 
resemble. The smaller vessels are chiefly distri- 
buted on the inner layer, which, owing to its vascu- 
larity, has been compared to the pia mater investing 
the brain. At the postero-superior border of the 
testicle, and a little to its outer side, the tunica 
albuginea forms an internal projecting body or pro- 
cess, which lodges the blood-vessels, and a portion 
of the glandular structure of the testicle, called the 
rete testis. This body is named after the anatomist 
who first described it the Corpus Highmori. It has 
since, however, been called by Sir A. Cooper the 
mediastinum testis, and he describes it as being 
formed by the tunica albuginea, which at that part 
is divisible into three layers. The first layer turns 
upon the spermatic cord, and unites with the sheath 
which covers the vessels. The second layer unites 
with a similar layer on the opposite side, and forms 
a thick substance, between the fibres of which in- 
terstices are left for blood-vessels and absorbents ; 
whilst the internal layer, uniting with that on the 
opposite side, as well as with the preceding layer of 
the tunica albuginea, forms the process called medi- 
astinum, which projects into the testis between the 
tubuli ; and it is in this substance that the seminal 
canals of the rete are placed. The mediastinum is 
therefore composed of two bodies ; the upper placed 
towards the spermatic cord, the lower towards the 
centre of the testis; in the upper are placed blood- 



38 THE TESTIS. 

vessels ; in the lower the canals of the rete. Its 
length varies from six to eleven lines. 

11. Glandular or Secreting Structure. 

The glandular part of the testis is very simple, 
and more easily demonstrated than the glandular 
structure of most other organs. It consists of 
numerous seminiferous vessels or tubes, supplied 
with blood-vessels, lymphatics, and nerves. Its 
colour is a grayish yellow or brown, more or less 
tinged with blood, and is paler in infants and old 
men than in adults. The tubes are collected into 
numerous lobes or lobules, invested by a fine cellular 
tissue, which, detached from the interior of the 
tunica albuginea, penetrates the gland, and sends 
out lateral processes forming septa, which separate 
and sustain the lobules. These septa at their 
origin partake of the fibrous character of the tunica 
albuginea, but as they converge towards the supe- 
rior border of the testis, occupied by the corpus 
Highmori, they become finer, and are gradually 
resolved into a delicate cellular tissue. The septa 
are traversed by numerous blood-vessels which mi- 
nutely divide in them before being distributed on 
the seminiferous tubes,^ 

* Sir A. Cooper states, that the inverted portion of the tunica albu- 
ginea, forming- the mediastinum testis, sends forth numerous liga- 
mentous cords, some of which pass to the anterior edge of the testis ; 
whilst others form shorter processes to support and invest the lobes, 
being met by similar ligamentous cords from the inner surface of the 
tunica albuginea. I have not been able to make out any such liga- 
mentous processes, passing into the substance of the testis, as are 



THE TESTIS. 39 

Tubuli Seminiferi. — These tubes, which form by 
far the bulk of the glandular structure of the testis, 
are very numerous, and radiate from all parts of 
the circumference of the organ towards the medi- 
astinum, making numberless convolutions, which 
progressively diminish as they approach the rete 
testis. Two or more of the tubuli being collected 
together, and invested by a common cellular tunic, 
form a lobe or lobule of a conical form, its apex 
terminating at the corpus Highmori. The lobes 
thus formed are not entirely distinct, but com- 
municate with neighbouring lobes ; the processes 
investing them are therefore incomplete, and the 
lobes cannot be separated from each other without 
division of some of the seminiferous tubuli. Krause 
estimates the number of the lobes as varying from 
404 to 484.* The tubuli are of a white colour and 
uniform size, but their calibre differs in different 
subjects, and varies a good deal according to the 
age of the subject and the state of activity of the 
testes, being larger in young adults and when dis- 
tended with semen than in old persons and when 
the gland is in a state of rest.t The size of the 
ducts also often differs in the two testes of the 
same subject. In general the calibre of the tubuli 

represented in Sir A. Cooper's work (part i. pi. 2, fig. 3.), which I have 
found to be an exaggerated view of the preparation from which it was 
taken. The cords described appear to me to consist chiefly of blood- 
vessels supported by slight fibrous processes from the tunica albuginea 
and cellular tissue. In a well-injected testis very little tissue of the 
nature of ligament can be found between the lobes. 

* Miiller, Archiv. fiir Anatomie, 1837, p. 22. 

I The following is from a Table of Measurements of the Seminal 



40 



THE TESTIS. 



corresponds to the size of the testis. Observers do 
not exactly agree in their estimates of the diameter 
of the tubuli. The average diameter of the unin- 
jected canal is estimated by Miiller at tV of a line, 
by Lauth* at rh of an inch. Krause found the 
tubuli, when filled with semen, to measure about 
tV of a line, and in old men and youths tV. Monro 
reckoned the number of the seminiferous tubes at 
300; Lauth made the average number 840, and 
he estimated the mean length of all the ducts 
united at 1750 feet. He found the individual ducts 



Tubes made by Mr. Gulliver. {Proceedings of the Zoological Society, 
July 26, 1842.) 





Size of 






Tubes in 




Age. 


Fractions of 

an English 

Inch. 


State of Testes. 


22 


ih to tV 


Scarcely any fluid in testes. Died of 
phthisis. 


42 


TT3 to ^V 


Some spermatozoa in epididymis. Died 
of phthisis. 


60 


ih to A 


No spermatozoa. Died of phthisis. 


86 


T-6 to i4o 


Died of pneumonia. Fatty matter in 
testes. No spermatozoa. 


8 


1 
4 2 2 


Died of phthisis. 


18 months 


Th to ^h 


Died of pneumonia. Child puny and 
emaciated. 


6 weeks 


jh to 2^0 


Died of pneumonia. Body much ema- 
ciated. 


still born 


T*T 


Well nourished fcetus ; born at full 
period. 


still born 


tJo to 2 J2 


Foetus weighed 6 lbs. 



The enlargement of the seminal tubes of birds in the spring, and of 
the mammalia at the rutting season, and in young animals generally 
as they become capable of reproduction, has been noticed by Wagner 
{Physiology, tr. by Willis, pp. 23 and 27), and further illustrated by 
Mr. Gulliver in the table from which the above observations in man 
were taken. 

* Mem. de ]a Societe, d'Hist. Nat. de Strasbourg, t. 1. 



THE TESTIS. 



41 



to vary in length, the mean being 25 inches. Krause 
estimated their entire length at 1015 feet. The 
membrane composing the tubuli is of a mucous 
character, as has been clearly proved by microscopic 
examination, and it is continuous with the mucous 
surface of the genito-urinary system. There is no 




A. Glandular structure of the testis, displayed by mercurial injec- 
tion. — After Lauth. 

a a a. Glandular substance of the testis subdivided into lobes, each 
lobe being- composed of convoluted tubuli closely packed. 

h. Rete testis. 

c c. Vasa efferentia. 

d. Inflected part of the vasa efferentia forming the coni vasculosi. 

e e. Dilatations of the efferent vessels. 

f. Body of the epididymis. 

g. Tail of the epididymis. 
}i. Vasculum aberrans. 

k. Straight part of the vas deferens. 

6 



42 THE TESTIS. 

appearance of an intertubular substance ; the ducts 
are merely connected by a loose network of vessels, 
and consequently readily admit of being separated 
and unravelled. The tubes, when successfully in- 
jected with quicksilver, form a beautiful anatomical 
preparation. Sir A, Cooper succeeded in filling the 
tubes with size injection ; but he has not described 
the mode in which it was effected, and other ana- 
tomists have failed in similar attempts. 

When the tubuli seminiferi are unravelled, they 
are found to divide, and form numerous anasto- 
moses which increase in frequency towards the cir- 
cumference of the testicle (see diagram b a^ a^). 
The tubuli thus form one vast network of com- 
munication, so that it is impossible to isolate com- 
pletely either a duct or a lobule. The credit of 
making this interesting discovery of the anasto- 
moses of the seminal tubes is due to Lauth. In 
only one instance did he succeed in finding a duct 
terminating in a blind pouch, and this he regarded 
as exceptional. Blind ends have been found, how- 
ever, more frequently by Krause. The anastomoses 
of the tubules have been observed in the rat and 
other animals as well as in man. The convolutions 
of the seminal tubes diminish in number as they 
approach the mediastinum, and cease altogether at 
a distance of from one to two lines, where two or 
more unite to form a single straight duct, termed 
vas rectum, which joins the rete testis at a right 
angle (a^, a^). The vasa recta are very slender, 
and easily give way when injected : their calibre, 
which is greater than that of the seminal tubes, is 



THE TESTIS. 



43 



estimated by Lauth at ih of an inch. Haller 
reckoned their number at twenty, which is, how- 
ever, too few. 



k 




Rete Testis, as its name implies, consists of a 
plexus of seminal tubes, which occupies the corpus 
Highmori, or mediastinum testis. The vasa recta, 
after penetrating the walls of this body, terminate 
in from seven to thirteen vessels, which, running 
parallel to each other in a waving course, and fre- 
quently dividing and anastomosing, form the rete 
testis (6). Lauth found the mean diameter of the 
vessels of the rete in injected preparations yV of ^n 
inch. According to Prochaska, these vessels are 

B. Diagram of the testis, after Lauth. 

a a a. Tabuli. 

a^ a^. Subdivisions and anastomoses of the tubuli. 



a'^ a^. Vasa recta. 

The other references are the same as in 



A. 



44 THE TESTIS. 

supplied with valves, but such is not the case. 
Small dilatations, however, are often found in dif- 
ferent parts of the plexus. 

III. The Excretory Parts, 

The epididymis, a continuation of the tSstis, is a 
body of a crescentic form, divided into an anterior 
and upper extremity, called. head, or globus major, 
which is firmly attached to the testicle ; a middle 
part or body, which is less in size, and separated 
from the gland by a pouch of the tunica vaginalis ; 
and a tail, or globus minor, connected to the testis 
by cellular tissue. The volume and weight of the 
epididymis vary in different subjects, but are pro- 
portionate to the size of the testis. It is longer 
than the testis, measuring about two inches in 
length and four or five lines in width. Its name 
(from s<ffi, upon, and §i§v^og, testis,) indicates its posi- 
tion, which is along the postero-superior border of 
the gland. The epididymis is chiefly made up of 
seminal canals connected and supported by a firm 
resisting cellular tissue. The ducts which spring 
from the upper part of the rete testis to form the 
epididymis are termed vasa efferentia. They are 
usually about twelve or fourteen in number, but 
vary from nine to thirty. The inflections of each 
of these efferent ducts are so arranged as to form 
in the head of the epididymis a series of elongated 
conical figures called coni vasculosi. These ducts 
at their commencement run straight for a distance 
of about one or two lines, when they form convolu- 



THE TESTIS. 



45 



I 



tions which become more numerous and close as 
the ducts recede from the testis. Their length 
varies, the upper ones being the shortest. Lauth 
found their average length to be seven inches four 
lines, and calculating their number at thirteen, he 
makes the united length of the vasa efferentia 
nearly eight feet. He states that the efferent 
ducts diminish in size from their commencement 
to their termination in the canal of the epididymis, 
where they are less than the 
seminiferous ducts of the testi- 
cle. (See fig. c.) As in the rete, 
round dilatations of variable 
size are often met with in 
these ducts. (See fig. a. ee.) 
The efferent ducts, after form- 
ing the coni vasculosi, succes- 
sively join a single duct, the 
canal of the epididymis, at 
irregular distances, the inter- 
mediate portions of the duct 
varying in length from half an 
inch to six inches. The effer- 
ent ducts are more slender than 
the canal of the epididymis, 
and frequently give way under the pressure of the 

C. An efferent vessel and a portion of the head of the epididymis 
magnified, to show the prog-ressive diminution of the canal of the cone, 
and the calibre of this vessel, in comparison with that of the canal of 
the epididymis. 

c. Vas deferens. 

d. Inflected portion of the duct. 

e e. Head of the epididymis.— After Lauth. 




46 



THE TESTIS. 



column of mercury when injected. The body and 
tail of the epididymis are entirely made up of 
the convolutions of the single canal in which 
the vasa efferentia terminate, closely connected 
by cellular tissue. Monro described this canal as 
gradually increasing in size from the head to the 
tail, and he estimated its calibre 
about its middle at -io of an inch. 
^^ Lauth states that its size is sub- 
ject to great irregularities in dif- 
ferent parts and in different sub- 
jects. This anatomist has par- 
ticularly described the convolu- 
tions of this duct, and has shown 
that they are regularly arranged 
in four series, which successively 
increase in size, the first being 
the smallest, and the fourth the 
largest. The arrangement will 
be best understood by reference 
to fig. D. Monro estimated the 
length of the canal at thirty feet 
eleven inches. Lauth found its mean length to be 
nineteen feet four inches eight lines. The parietes 
of the canal are strong and bear considerable re- 
sistance. The canal of the epididymis terminates 




D. Canal of the epididymis partly unravelled to show the four 
series of inflections v/hich the duct undergoes in the several divisions 
of the epididymis. 

o 0. First series of inflections. 

p p. Second series. 

q q. Third series. 

T r. Fourth series.— After Lauth. 



THE TESTIS. 



47 



in the excretory duct of the testis, the vas deferens, 
and is usually contracted at the part where the 
two join. It was calculated by Monro that the 
semen before arriving at the vas deferens traverses 
a tube forty-two feet in length. Lauth, however, 
makes the whole distance but little more than 
twenty- two feet. 

[I annex a drawing made from a mercurial injec- 
tion of the testicle, by J. P. Hopkinson, and given 
by him to the University of Pennsylvania. It is 
laid open so that the rete testis is in the centre. 
It shows well the tubuli seminiferi on each side, the 
vasa recta, the rete testis, the coni vasculosi, &c. It 
seemed to possess no vasculum aberrans. — Am. Ed.] 







^? m. 



Vascuhim aberrans.— This name was given by 



48 THE TESTIS. 

Haller to a blind duct or caecal appendage often 
found connected either to the epididymis or vas de- 
ferens. It is more commonly attached at the angle 
formed by the termination of the former in the 
latter. (See figs. a. and b. h.) It forms a convoluted 
duct as large as the canal of the epididymis, which 
is contracted at its insertion, and terminates in a 
blind and often dilated extremity. Sometimes after 
being dilated for a certain distance it diminishes, 
and becoming very minute, is lost in the cellular 
tissue of the cord. It usually passes up the cord 
for about two or three inches, but has been found 
to extend as far up as the brim of the pelvis. The 
length of this appendage when unravelled varies 
from one to twelve or fourteen inches. The vas- 
culum aberrans is not constantly present ; indeed 
Monro found it only four times in sixteen, but I 
believe with Lauth that it exists more frequently. 
Occasionally there is more than one, and as many 
as three have been found both by Lauth and Sir A. 
Cooper. Hunter regarded these ducts as supernu- 
merary vasa deferentia of a nature similar to the 
double ureters.^ Miiller states that their office is 
evidently the secretion of a fluid which they pour 
into the epididymis.f I am inclined to think, how- 
ever, that the duct does not serve any particular 
office ; but is a sort of diverticulum, which, though 
common, must be viewed as accidental, like the 
process not unfrequently connected with the intes- 
tinal canal. 

* Works, by Palmer, vol. iv. p. 24. 

I Physiology, trans, by Baly, vol. i. p. 456. 



THE TESTIS. 49 

Vas deferens, the excretory duct of the testicle, 
commences from the tail of the epididymis, and 
terminates in one of the ejaculatory canals behind 
the bladder. Arising from the contracted part of 
the canal of the epididymis at an acute angle, it 
ascends along the inner side of this body, from 
which it is separated by cellular tissue and the 
spermatic arteries " and veins. A right or left 
testis may thus always be distinguished by the cir- 
cumstance that when the testis is in position, the 
vas deferens is situated on the inner or jnesial side 
of the organ. In this part of its course, for the 
distance of about an inch and a half, or more, the 
vas deferens forms numerous convolutions (see figs. 
A. and B. i), which gradually cease as the duct 
mounts above the testis. The inflected part of the 
vas deferens, when unravelled, was found by Lauth 
to measure six inches and a half It afterwards 
takes a direct course (k) up the spermatic cord to 
the inguinal canal, passing behind and at a short 
distance from the spermatic arteries and veins. 
On entering the abdomen at the internal ring, it 
quits the spermatic vessels and descends into the 
pelvis, passing at first by the side of, and after- 
wards behind and below the bladder on the inner 
side of the corresponding vesicula seminalis, the 
excretory duct of which it joins at an acute angle 
to form the ejaculatory canal. The vas deferens 
is nearly uniform in thickness until it reaches the 
vesicula seminalis, and is lined by a fine membrane 
of a mucous character, which is continuous with 
the urethra. It is roimd and indurated, and harder 



50 THE TESTIS. 

than any other excretory duct in the body, by 
which character it is easily distinguished, when 
handled, from the other parts constituting the sper- 
matic cord. Many anatomists have entertained 
the opinion that the parietes of this duct are mus- 
cular. It is distinctly so in the bear, bull, and 
other animals. On careful examination, however, 
of sections of the human vas deferens in the micro- 
scope, I could discover nothing more than simple 
fibrous tissue. 

IV. The Vessels and Nerves. 

Spermatic Vessels. — The spermatic arteries, the 
chief vessels supplying the testes, arise in pairs, at 
a very acute angle, from the fore part of the aorta, 
immediately below the renal arteries. Their origin 
is subject to considerable varieties. The two sel- 
dom arise at the same level, and the right is often 
a branch of the right renal artery. Sometimes one 
or both come off from the superior mesenteric. 
Occasionally there are two spermatic arteries on 
one or both sides, arising in the regular way. All 
these deviations are more frequently met with on 
the left than on the right side of the body. Each 
artery pursues a tortuous course downwards and 
outwards, passing behind the peritoneum obliquely 
across the psoas muscle and ureter, to which, as 
well as to the surrounding cellular tissue, it gives 
off several branches. The artery then enters the 
inguinal canal through the internal ring, and 
emerging at the external, passes down the cord, 



THE TESTIS. 51 

being surrounded in its course by the spermatic 
veins. The further distribution of the artery is 
thus correctly described by Sir A. Cooper. When 
the artery reaches from one to three inches from 
the epididymis, varying in different subjects, it 
divides into two branches, which descend to the 
testicle on its inner side, opposite to that on which 
the epididymis is placed ; one passing on the ante- 
rior and upper, the other to the posterior and lower 
part of the testis. From the anterior branch the 
vessels of the epididymis arise : first, one passes to 
its caput ; secondly, another to its body ; and, 
thirdly, one to its cauda and the first convolutions 
of the vas deferens, communicating freely with the 
deferential artery. The spermatic artery, after 
giving off branches to the epididymis, enters the 
testis, by penetrating the outer layer of the tunica 
albuginea ; and dividing upon its vascular layer, 
they form an arch by their junction at the lower 
part of the testis, from which numerous vessels 
pass upwards ; and then descending, they supply 
the lobes of the tubuli seminiferi. Besides this 
lower arch there is another passing in the direction 
of the rete, extremely convoluted in its course, and 
forming an anastomosis between the principal 
branches. The testis receives a further supply of 
blood from another vessel, the artery of the vas 
deferens, or posterior spermatic artery, which arises 
from one of the vesical arteries, branches of the 
internal iliac. This artery divides into two sets of 
branches, one set descending to the vesicula semi- 
nalis, and to the termination of the vas deferens ; 



52 THE TESTIS. 

the other, ascending upon the vas deferens, runs in 
a serpentine direction upon the coat of that vessel, 
passing through the whole length of the spermatic 
cord ; and when it reaches the cauda epididymis, 
it divides into two sets of branches, one advancing 
to unite with the spermatic artery to supply the 
testes and epididymis, the other passing backwards 
to the tunica vaginalis and cremaster. 

The spermatic veins spring in three sets from 
the testis, one from the rete and tubuli, and another 
from the vascular layer of the tunica albuginea, 
and a third from the lower extremity of the vas 
deferens. The veins of the testis pass in three 
courses into the beginning of the spermatic cord ; 
two of these quit the back of the testis, one at its 
anterior and upper part, and a second at its centre ; 
and these, after passing from two to three inches, 
become united into one. The other column ac- 
companies the vas deferens. There is also a large 
vein just above the testis, which crosses to join the 
three columns. The veins of the epididymis are 
one from the caput, another from its body ; one 
from its cauda, and another from its junction with 
the vas deferens, beside some small branches ; they 
terminate in the veins of the spermatic cord. The 
veins, after quitting the testis, become extremely 
tortuous, and frequently divide and inosculate in 
the cord, forming a plexus termed vasa pampini- 
formia. These communications cease as the veins 
approach the ring, which they enter, and ascending 
along the psoas muscle in company with the sper- 
matic artery, unite to form a single vein, which 



THE TESTIS. 63 

usually terminates on the right side in the vena 
cava inferior, and on the left in the renal vein ; 
though this is subject to some variety. The left 
spermatic veins pass under the sigmoid flexure of 
the colon. Many anatomists speak of the sperma- 
tic veins as being destitute of valves, which they 
assign as one of the reasons for the occurrence of 
varicocele. I have several times injected these veins 
with alcohol, and on laying them open, have ob- 
served valves in the larger vessels, and I have also 
found injections thrown into the veins arrested by 
the valves. They are seldom seen, however, very 
near the testis, or in the smaller veins, forming the 
plexus ; nor have 1 observed them within the ab- 
domen. 

Absorbents. — The absorbent vessels of the testis 
are very numerous, and arise from every part of its 
internal structure and coats. They unite to form 
four or ^ve trunks, which ascend along the cord, 
and traverse the inguinal canal, without communi- 
cating with the glands in the groin, but pass up- 
wards in front of the psoas muscle, behind the pe- 
ritoneum, and terminate in the lumbar glands, on 
the side of the aorta. 

Nerves. — The nerves of the testis are derived 
chiefly from the renal plexus, but partly also from 
the superior mesenteric and aortic plexuses. These 
nerves descend in company with the spermatic 
artery to the cord, where, being joined by branches 
from the hypogastric plexus, which pass along the 
vas deferens, they form together the spermatic 
plexus, the branches of which are intermingled 



54 THE TESTIS. 

with the vessels of the cord, and ultimately ter- 
minate in the substance of the testis. A few twigs 
from the external spermatic nerve may also be 
traced to the coverings of the gland. The minute 
distribution of these nerves forms a very difficult 
dissection. 

The Testis in the Foetus, and its Descent into the 
Scrotum, 

The testes are first developed and situated in the 
abdomen. They originate from the lower part of 
the Corpora Wolffiana, and may be detected at an 
early period of foetal existence immediately below 
the kidneys on the fore- part of the psose muscles, 
to which they are attached by a reflection of peri- 
toneum. This membrane closely invests the testes 
in the same manner as it covers the other abdo- 
minal viscera. The position of the testis in the 
abdomen is nearly the same as it maintains after 
its descent into the scrotum. The epididymis, 
however, is relatively of larger size than in the 
adult, being about one third that of the body of 
the organ. Attached to each testis whilst in the 
abdomen is a peculiar body which was termed by 
Mr. Hunter, who first described it, the guhernacu- 
lum. It is a soft solid projecting body of a conical 
form, which varies somewhat in shape and size at 
different periods of the testicular descent, becoming 
shorter and thicker as the gland approaches the 
abdominal ring. It is situated in front of the psoas 
muscle, to which it is connected by a reflection of 



THE TESTIS. 55 

peritoneum. Its upper part is attached to the 
inferior extremity of the testis, lower end of the 
epididymis, and commencement of the vas de- 
ferens. The lower part of this process passes out 
of the abdomen at the abdominal ring, and dimi- 
nishing in substance and spreading, terminates in 
three processes, each of which has a distinct attach- 
ment. The central part and bulk of the guberna- 
culum is composed of a soft, transparent, gelatinous 
substance, which, on examination in the microscope, 
is found to consist of nucleated cells, the primitive 
cellular tissue : this central mass is surrounded by 
a layer of well-developed muscular fibres, which 
may be distinguished by the naked eye, and which 
can be very distinctly recognised in the microscope 
to be composed of " striped elementary fibres." 
These muscular fibres, which may be traced the 
whole way from the ring to the testis, are sur- 
rounded by a layer of the soft elements of the cel- 
lular tissue similar to that composing the central 
mass ; and in the same way as the testis the whole 
process, except at its posterior part is invested 
with peritoneum. On carefully laying open the 
inguinal canal, and gently drawing up the guber- 
naculum, the muscular fibres may be traced to the 
three processes, which are attached as follows : the 
external and broadest is connected to Poupart's 
ligament in the inguinal canal ; the middle forms 
a lengthened band, which escapes at the external 
abdominal ring, and descends to the bottom of the 
scrotum, where it joins the dartos ; the internal 
passes in the direction inwards, and has a firm 



56 THE TESTIS. 

attachment to the os pubis and sheath of the rectus 
muscle. Besides these, a number of muscular 
fibres are reflected from the internal oblique on 
the front of the gubernaculum. It thus appears 
that the attachments of the muscle of the guber- 
naculum and those of the cremaster in the adult 
are exactly similar. I have succeeded in tracing 
out the former before the testis has descended, at 
different stages of the process, and immediately 
after its completion ; and of the identity of the two 
no doubt can be entertained. Carus was of opinion 
that the cremaster does not exist before the descent 
of the testis ; but that it is formed mechanically, 
by the testis pushing before it the lower fibres of 
the internal oblique, so as to form the loops of this 
muscle."^ This view, which has been adopted by 
M. Jules Cloquet, and after him by many of the 
anatomists of this country, is, as I have shown else- 
where, clearly erroneous and inaccurate.t 

The vessels of the testis in the foetus arise from 
the nearest large trunks, and enter the substance 
of the gland at its posterior part. The artery of 
the vas deferens, from which the gubernaculum is 
chiefly supplied, is nearly as large as the sper- 
matic. The long course taken by the arteries and 
veins of the testis when in the scrotum is thus ex- 
plained by the original site of the organ, to which 
circumstance must also be ascribed the sharp turn 

* Comparative Anatomy by Gore, vol. xi. p. 347. 

t Vide Observations on the Structure of the Gubernaculum, and on 
the Descent of the Testis in the Foetus, by the Author, in London 
Medical Gazette, April 10, 1841, or in the Lancet of the same date. 




THE TESTIS. , 57 

upwards of the vas deferens from the epididymis, 
the two being continuous in a direct line, whilst 
the testis is in the abdomen. Between the fifth 
and sixth month of foetal existence, sometimes 
later, the testis begins to move from its situation 
near the kidney towards the 
ring, which it usually reaches 
about the seventh month. 
During the eighth month it 
generally traverses the ingui- 
nal canal, and by the end of 
the ninth arrives at the bottom 
of the scrotum, in which situation it is commonly 
found at birth. The testis, both during its pas- 
sage to the ring, and through the inguinal canal, 
carries along with it its original peritoneal coat, 
adhering by the reflection of this membrane, 
during the whole of its descent, to the parts 
behind, in the same manner as whilst situated 
below the kidney. The testis, therefore, does 
not pass directly and abruptly into a pouch pre- 

E. Diagram of the gubernaculum and testis previous to its descent, 

1. The kidney. 

2. The testis. 

3 3. The peritoneum. 

4. Vas deferens passing down into the pelvis by the side of the 
bladder. 

5. The bladder. 

6. The abdominal ring. 
7 7. Poupart's ligament. 

8. Pubic portion of the cremaster. 

9. Fibres of the cremaster arising from Poupart's ligament. 

10. Portion of the gubernaculum attached to the bottom of the 
scrotum. 



58 THE TESTIS. 

pared to receive it, but carries the peritoneum 
with it, continuing to be connected to the parts 
behind by the reflection of the membrane, between 
the folds of which the vessels and nerves join the 
gland. In the passage of the testis from the ab- 
domen to the bottom of the scrotum, the guber- 
naculum, including its peritoneal investment and 
muscular fibres, undergoes the same change as that . 
which takes place in certain of the rodentia at the 
access of the season of sexual excitement ; the mus- 
cle of the testis is gradually everted, until, when 
the transition is completed, it forms a muscular 
envelope external to the process of peritoneum, 
which surrounds the gland and front of the cord. 
As the testis approaches the bottom of the scro- 
tum, the gubernaculum diminishes in size, owing | 
to a change in the disposition of its cellular ele- 
ments ; the muscular fibres, however, undergo 
little or no diminution, and are very distinct around 
the tunica vaginalis in the recently-descended testis. 
The mass composing the central part of the guber- 
naculum, which is so soft, lax, and yielding, as in 
every way to facilitate these changes, becomes 
gradually diffused, and after the arrival of the 
testis in the scrotum contributes to form the loose 
cellular tissue which afterwards exists so abun- 
dantly in this part : the middle attachment of the 
gubernaculum, which may be traced to the dartos 
at the bottom of the scrotum, gradually wastes 
away, and soon becomes indistinct, though slight 
traces of this process often remain to the latest 
period of life. Thus, after death, in dragging the 



THE TESTIS. 59 

testis of an adult out of the scrotum by pulling 
the cord, the lower part of the gland, which is 
uncovered by serous membrane, is often found 
connected to the bottom of the scrotum by a band 
of firm and dense cellular tissue, which requires 
division with the scalpel. This band is the remains 
of the middle attachment of the gubernaculum. 
In cases in which the testis has been retained in the 
groin, I have traced a cord of dense tissue from 
the gland to the lower part of the scrotum."^ 
After the arrival of the testis in the scrotum, 
the peritoneum, with which it is closely invested, 
its original envelope, becomes the inner layer of the 
tunica vaginalis ; whilst the pouch around, which 
is continuous with it, forms the outer layer, or 
vaginal sac. Immediately after the descent of the 
testis, this bag communicates with the abdomen, 
and in quadrupeds continues to do so during life ; 
but in the human subject it soon begins to close, 
and when the fa3tus is ushered into the world, the 
abdominal orifice is often shut, and the whole canal 
from the ring to the upper part of the testis is in 
general completely obliterated in the course of the 
first month after birth. The obliteration is effected 
by an intimate union of the surfaces of the serous 

* Mr. Hamilton lately afforded me the opportunity of dissecting the 
parts in a lad aged jfifteen, both of whose testes had not descended lower 
than just outside the external rings. He died of fracture of the skull. 
The body was well formed. I found a broad fibrous band proceeding 
from the lower part of each testis to the bottom of the scrotum. Mr. 
N. Ward, who examined this band for me in the microscope, states, 
that he distinctly recognised striped muscular fibres in it. The fact 
is interesting, but requires, perhaps, confirmation. 



60 THE TESTIS. 

membrane. It sometimes does not take place at 
all,^ or is delayed or only partially completed. 
Congenital hernia, or hydrocele, is the result of a 
failure in this process ; and other forms of hydro- 
cele are occasioned by imperfect obliteration of the 
canal, as will be hereafter explained. 

Much difference of opinion exists as to the im- 
mediate cause of the descent of the testis. Hunter, 
Meckel, and others, came to the con- 
clusion that the muscular fibres of 
the cremaster are insufficient to 
bring the testis lower down than the 
abdominal ring, and complete the 
descent. They were not, however, 
acquainted with the attachment of this muscle to 
the pubes external to the ring, or it would be diffi- 
cult to understand why Mr. Hunter, after arriving 
at the conviction that the cremaster passes up to 
the testis whilst in the abdomen chiefly from 
analogy, was not induced by the same process of 
reasoning to conclude, that a muscle capable of 

* The communication constantly remains open in quadrupeds, the 
chimpanzee, according to Mr. Owen, being the only animal in which 
the tunica vaginalis forms a shut sac. 




F. Diagram of the testis immediately after its descent, the cremas- 
ter being everted. 

1. The testis. 2. The shortened gubernaculum. 

3 3. The peritoneum. 

4. Portion of the cremaster arising from Poupart's ligament. 

5. Pubic portion of the muscle. 

This diagram is partly taken from a plan by Mr. Erasmus Wilson 
(Anatomist's Vade Mecum, second edition), who has adopted my views 
of the descent of the testis. 



THE TESTIS. 61 

drawing down the testicle in animals would be 
adequate to accomplish the same purpose in the 
foetus. The necessity for some active agent to 
effect this change in the latter would appear to be 
greater even than in animals, since, in the usual 
position of the foetus in utero, the passage of the 
testis is contrary to gravitation, and unaided by 
the movements of respiration. Now, when we 
consider the attachments and connexions of this 
muscle in the foetus, the perfect condition of its 
fibres as ascertained by microscopical examination, 
and the circumstance that there are no other means, 
no other motive powers by which this change can 
be effected, or in any way promoted, I think there 
is no reason to doubt that the cremaster executes 
the same office in the human embryo, as that which 
it undoubtedly performs in certain animals at a 
particular season. The fibres proceeding from 
Poupart's ligament and the obliquus internus tend 
to guide the gland into the inguinal canal, those 
attached to the os pubis to draw it below the ab- 
dominal ring, and the process descending to the 
scrotum to direct it to its final destination. As 
the descent approaches completion, the muscular 
fibres which perform so important a part in it 
gradually become everted, and, instead of drawing 
down the testicle, acquire the new functions of 
elevating, supporting, and compressing it. 

Spermatic Fluid. 
The sperm or secretion of the testis is a thick 
tenacious fluid, of a whitish or grayish-white colour, 



62 



THE TESTIS. 



and of greater specific gravity than water. It has 
an alkaline reaction, and is composed of albumen, 
phosphatic and hydrochloric salts, and a peculiar 
animal matter called spermatine. According to the 
analysis of Vauquelin, human spermatic fluid con- 
sists of the following ingredients: 



Water 


- 90 


Animal mucus 


6 


Free soda 


1 


Phosphate of lime 


3 


Peculiar animal principle 


- 



100 



When first voided, the sperm has a peculiar 
odour, which has been compared to that of the 
farina of the Spanish chestnut ; 
but this odour appears to be 
derived from the secretions of 
the vesiculce seminales, pros- 
tate, and the mucous^ glands 
of the urethra, which are al- 
ways mixed with it when eva- 
cuated, as pure semen taken 
from the epididymis or vas de- 
ferens has no such smell. On 
examination in the microscope, with a high power, 
this fluid is found to contain a multitude of minute 
bodies closely crowded together, which in recent 
semen display very lively movements. These bo- 
dies (1111) are the seminal animalmles, or 




THE TESTIS. 63 

spermatozoa, as they are more properly termed ; for 
it is yet a question amongst physiologists, whether 
they are independent parasitic animals, or merely 
animated particles of the organism in which they 
exist. A spermatozoon consists of a flattened oval 
and perfectly transparent body, terminating in a 
filiform tapering tail, which together measure from 
joth to 4Vth of a line in length. The spermatic 
fluid also contains a number of minute round 
colourless granular corpuscles (2), which vary in 
quantity, but are usually much less numerous than 
the spermatozoa. Both these elements of the 
sperm are suspended in a clear transparent fluid, 
termed the liquor seminis. Wagner has shown 
that the spermatozoa are developed within cells, 
and originate from the spermatic granules being 
formed by the dispersion of the nuclei of these 
cells.* 

The spermatozoa are peculiar to the spermatic 
fluid and the chief characteristic of this secretion. 
They are always present in it after the age of 
puberty, and do not disappear whilst man retains 
the power of procreation, having been met with in 
persons of a very advanced age. They live for 
many hours after ejaculation ; blood produces no 
effect on them, but urine renders their motions 
feeble, and hastens their death. The quantity of 

* Much curious information respecting the spermatic fluid may be 
found in Wagner's Physiology, tr. by Dr. Willis, Miiller's Physiology, 
tr. by Dr. Baly, and in Lallemand, Des Pertes Seminales Involon- 
taires, t. 2. 



64 THE TESTIS. 

spermatic fluid emitted in sexual union varies from 
one to two or three drachms. 

The Functions of the Testis. 

On surveying the structure of the testis, the 
anatomist cannot fail to remark the great extent of 
secreting surface afforded by the numerous, long 
and tortuous tubuli, and the length and complexity 
of the single excretory duct through which the 
seminal fluid has to pass. The extent of the duct 
is indeed so remarkable, that many physiologists 
have been led to suppose that the semen is further 
elaborated or perfected in its passage through its 
convoluted mass, constituting the epididymis. An 
examination of the spermatic fluid taken from the 
testis and its duct both in man and animals, under 
all circumstances and at all periods, and the vary- 
ing state of the discharge in cases of spermatic 
fistula, leave little room to doubt that secretion 
takes place from the continuous membrane forming 
the tubular canals only during the period of sexual 
excitement, or under the influence of -sexual feelings 
and desires. 

From birth to the period of puberty the testes 
remain small, and increase very little in size in 
proportion to other parts f but as the body on the 

* The little alteration which the testes undergo before puberty may 
be seen by reference to the table of measurements of the seminal 
tubes at different ages in the foot-note at page 40. It will be noticed 
that the size of the tubes differed but little at the ages of eighteen 
months and eight years. 



THE TESTIS. 65 

arrival of puberty becomes stamped with the cha- 
racters of the male sex, these organs rapidly enlarge, 
their glandular structure becomes much more de- 
veloped, and being excited begins to exercise its 
office of secretion, no spermatozoa being found in 
it until this period arrives. The age at which the 
testes thus become developed varies in different 
climates and in different constitutions, and is in- 
fluenced by the mode of life and circumstances in 
which the individual is placed. The inhabitants of 
warm climates reach the age of puberty much 
earlier than those of cold countries. In this part 
of Europe it takes place from the age of fourteen 
to seventeen years, according to circumstances. A 
boy reared in the country of a moral disposition 
and active habits does not experience the force of 
the sexual appetite till the body is well developed, 
and nature permits the gratification of his passion 
without injury to the constitution. It is otherwise, 
however, with the young inhabitant of a city and 
the associate of the dissolute. Before puberty is 
complete and the body fully formed, desire is pre- 
maturely aroused by impure addresses to the 
imagination, and the developement of the testes is 
hastened, and they are called into action earlier 
than if they were left solely to the impulse of 
nature. Unlike the animal creation the testes in 
man are ready at all seasons to perform their office. 
The desires subside and the secretion of the semen 
becomes languid as life advances, though they 
seldom cease entirely till the age of sixty-five or 
seventy. Indeed, I have several times discovered 

9 



66 THE TESTIS. 

spermatozoa in the testes of men upwards of 
seventy years of age, and once in the testicle of a 
tailor who died at the age of eighty-seven ; and 
there are instances on record of persons retaining 
the procreative faculty to the age of one hundred 
years ; but in these cases, as in the well-known 
instance of old Parr, the general bodily powers 
were also preserved in a very extraordinary degree.* 
■ " To the use of the sexual organs for the con- 
tinuance of his race man is prompted by a power- 
ful instinctive desire, which he shares with the 
lower animals. This instinct is excited by sensa- 
tions ; and these may either originate in the sexual 
organs themselves or may be excited through the 
organs of. special sensation. Thus in man it is 
most powerfully aroused by impressions conveyed 
through the sight or the touch : in many other 
animals, the auditory and olfactive organs commu- 
nicate impressions which have an equal power ; and 
it is not improbable that, in certain morbidly ex- 
cited states of feeling, the same may be the case in 
ourselves. That local impressions have also very 
powerful effect in exciting sexual desire must have 
been within the experience of almost every one ; 
the fact is most remarkable, however, in cases of 
satyriasis ; which disease is generally found to be 
connected with some obvious cause of irritation of 



* Old Parr, who lived to the great age of 152, was dissected by the 
celebrated Harvey ; and it is stated, " Genitalibus erat integris, neque 
retracto pene neque extenuato, neque scroto distento ramice aquoso 
ut in decrepitis solet, testiculis etiam integris et magnis." Bettus de 
Ortu et Natura Sanguinis, p. 320. 



I 



THE TESTIS. 67 

the generative system, such as pruritus, active con- 
gestion," &c. — " The instinct, v\^hen once aroused 
(even though very obscurely felt), acts upon the 
mental faculties and moral feelings, and thus be- 
comes the source, though almost unconsciously so 
to the individual, of the tendency to form that kind 
of attachment tov^ards one of the opposite sex, 
which is known as love. This tendency cannot be 
regarded as a simple passion or emotion, since it is 
the result of the combined operations of the reason, 
the imagination, and the moral feelings ; and it is 
in the engraftment (so to speak) of the psychical 
attachment upon the mere corporeal instinct that 
a difference exists between the sexual relations of 
man and those of the lower animals."^ 

The part of the brain which is the seat of the 
sexual appetite is supposed by the phrenologists to 
be the cerebellum, between which and the genital 
organs a close sympathy is said to exist. There 
are several facts which give countenance to this 
opinion, and on the other hand many equally un- 
favourable to, and totally incompatible with it. I 
shall not stop to investigate this curious question ; 
but I may remark that the statements of the phre- 
nologists have not always been remarkable for their 
accuracy, and that their reasoning in regard to it 
is often unsound and fallacious.! No doubt, how- 

* Dr. Carpenter's Principles of Human Physiology, p. 619. 

f The reader interested in this subject may consult Dr. Carpenter's 
able work on Human Physiology, p. 207. Professor Owen, in his 
lectures on the nervous system at the College of Surgeons, adduced 
many striking facts apparently irreconcilable with the views of the 
phrenologists respecting the office of the cereb ellum. 



68 THE TESTIS. 

ever, can be entertained that the mind is intimately 
connected with the procreative facuky, and that 
the brain controls and animates the desire for 
sexual enjoyment. An affection of the brain or 
the mind, as sadden disgust, arrests the secretion 
of the testes, and extinguishes all desire as quickly 
and effectually as a strong mental impression stops 
the secretion of the gastric juice and takes away 
all appetite for food ; and in the chapter on Atro- 
phy of these glands I shall have occasion to men- 
tion cases in which the genital function has been 
permanently annihilated, and complete wasting of 
the testes has resulted from injuries of the head. 
In respect to the mode in which these organs are 
called into action they bear considerable analogy 
to the lachrymal, salivary, and mammary glands, 
in which secretion is excited both by the influence 
of the mind, and by mechanical contact or local 
irritation of the extremity of the excretory duct, the 
glans penis holding the same relation to the testis 
as the mucous membrane of the mouth does to 
the salivary glands, or as the nipple does to the 
mamma. 

The influence of the testes and brain upon each 
other appears, as has been already observed, to be 
reciprocal ; for not only may desire be aroused by 
local irritation and exciting the testicles to secrete, 
but the passion itself never arises when these glands 
are removed before puberty, and is extinguished 
by their extirpation afterwards. Nothing indeed 
illustrates more forcibly the intimate relation which 
the functions of the testicles bear to the mind and 



THE TESTIS. 69 

<^haracter of the individual, and the general orga- 
nization of the body, than the effects of castration. 
When it is performed in early life, the changes 
characteristic of puberty never ensue. There is a 
deficiency of the beard, the muscles do not acquire 
the manly tone and vigour, the cellular and adipose 
tissues abound, the voice retains the high and clear 
tones of infancy, and the mind remains deficient in 
energy and strength. When the testes are removed 
after the period of puberty, the eunuch loses in 
part, though not entirely, his former masculine 
character. His beard grows less abundantly, his 
voice becomes shrill, and there is diminished energy 
and vigour in all his sentiments and actions. These 
changes in the constitution, as well as the loss of 
the sexual instinct which occur in men thus de- 
graded, do not immediately succeed the removal of 
the testes, but take place gradually ; and there are 
well-attested cases^ in which desire has been ex- 
perienced and connexion with emission accom- 
plished many months after the loss of these organs. 
This shows that the passion is not solely dependent 
on the secretion of semen, though it mvariably de- 
clines when the power of procreation becomes lost. 
The emissions in such cases are imperfect and 
fruitless, consisting merely of the secretions of the 
vesiculce seminales and prostate. A man deprived 
of his testes, after arriving at puberty, fully esti- 
mates and acutely feels his loss, whilst a person 

* Vide the cases mentioned in chapter xvii. 



70 THE TESTIS. 

castrated when young is often indifferent to his 
peculiar condition, being less sensible of the loss of 
powers whose influence he is incapable of appre- 
ciating, and of a source of pleasure which he has 
never been able to enjoy .^ 

The testes not being parts essential to life are 
subject to different laws from those which regulate 
the actions of the vital organs. Their functions 
may be suspended, or they may remain in abeyance 
for an indefinite period without injury to the 
glands, or any material effect on the constitution. 
In persons of recluse and studious habits the func- 
tions of these organs often continue dormant for 
years. Like the mammae in the unmarried female, 
though inactive, they remain sound and competent 
for secretion when duly excited and called upon to 
exercise their functions. The opinion, that in man- 
hood the testes waste from long-continued chastity, 
I believe to be as erroneous as its tendency is ob- 
viously injurious and immoral, in furnishing an 
excuse for illicit intercourse to those who cannot 
otherwise indulge the sexual appetite.t It often 
happens that the passions are excited without an 

* M. Mojon, who has studied the condition of castrated individuals, 
mentions as a constant fact, that they are subject to periodic bleedings, 
occurring- generally from the- hssmorrhoidal vessels : he supposes that 
the blood necessary to the developement of the genital parts and of the 
beard, as well as that destined to the formation of the sperm, is de- 
termined to the vessels of the rectum, which becoming congested and 
weakened, allow their contents to escape. Memoire sur les EfFets de 
la Castration dans le Corps Humain, p. 28. 

f Vide further observations on this subject in chapter ii. 



THE TESTIS. 71 

opportunity being afforded for their gratification. 
Under these circumstances the testes become en- 
cumbered with secretion, which would prove inju- 
rious to them were they not relieved by occasional 
nocturnal emissions, or ejaculations of the semen 
under the influence of dreams during sleep, which 
appear to be a salutary provision to obviate the 
inconveniences which might result as well from 
ungratified desires as from an accumulation of 
semen in the ducts. In the adult the moderate 
indulgence of the passions is favourable to health 
and to the maintenance of the powers both of the 
mind and body. A certain degree of vigour, how- 
ever, is necessary to bear the nervous excitement 
attending it ; hence in advanced years and in weak 
and susceptible individuals the frame is unable to 
sustain frequent connexion with impunity. The 
old man often pays dearly for a matrimonial con- 
nexion with a young woman by an attack of 
paralysis, or else an exhausted frame, premature 
debility, and death. Similar consequences ensue in 
the young from the pernicious influence of excessive 
indulgence or self-abuse. Whenever the sexual act 
is followed by a sense of debility and lassitude, an 
uncomfortable feeling in the head, and disinclina- 
tion for either physical or mental exertion, the limits 
consistent with health have been exceeded. The 
hurtful effects of frequent sexual intercourse result 
less from the drain upon the system by the discharge 
of the seminal secretion than from the nervous ex- 
citement attending the act, as is evinced in cases of 
excessive masturbation, in which the amount of 



72 THE TESTIS. 

fluid evacuated bears no proportion to the exhaus- 
tion of the bodily powers, and the prostration of 
the mental faculties. Not only is the enjoyment 
heightened, but the effects of coition on the consti- 
tution are far less depressing when the necessary 
energy is supplied by the stimulus of a warm at- 
tachment, than when the appetite is irregularly 
indulged in fornication or in solitary abuse. The 
nervous system is invigorated by the passion, and 
acquires a power which enables it to bear the ex- 
citement of repeated coition ; whilst the debauchee 
often suffers as severely in his health as he always 
does in his morals from the unrestrained gratifica- 
tion of his animal propensities. The impulse for 
commerce exists in different degrees of force in 
different men, those of a sanguine temperament 
being most prone to indulge, and best able to do 
so with impunity. Indolent habits, and allowing 
the mind to dwell on subjects of a lascivious cha- 
racter, tend greatly to increase it. On the contrary, 
it is diminished by muscular exertion and mental 
occupation. The indifference of the hard student 
to such pleasures has been a matter of common 
remark ;* active gymnastic exercises also seem to 
have considerable influence in subduing sensual 
desires. He who experiences difficulty in restrain- 
ing his passions should be warned that the more 
they are indulged the more difficult are they of 
control ; and before resorting to illicit pleasures. 



* Love seldom haunts the breast where learnuig lies, 
And Venus sets ere Mercury can rise. — Pope. 



» 



t 



I 



THE TESTIS. 73 

he will do well to have recourse to the sports of 
the field, or to such exercises as cricketing and 
rowing, combined with close mental application. 
Man best asserts his superiority to the brute crea- 
tion and the dignity of his character by effectually 
restraining his erotic desires. The passions should 
be subject to the dominion of reason and moral 
influence ; and in health, however strong, they are 
never so irresistible as not to be under the control 
of volition. 



10 



PART IL 

DISEASES OF THE TESTIS. 
CHAPTER I. 

CONGENITAL IMPERFECTIONS AND MALFORMATIONS. 
SECTION L 

NUMERICAL EXCESSES AND DEFECTS. 

Supernumerary Testis, — Cases of supernumerary 
testis are mentioned in the writings of the old 
authors, and persons have been described with four 
or five of them, accompanied with a proportionate 
increase in the venereal appetite. Nearly all these 
cases are of a very doubtful character, the observa- 
tions during life not having been confirmed by dis- 
section after death. Such must be remarked of 
the case of ■Trsvropxo?, or man with ^we testicles, men- 
tioned by Schaarf,^ and with that of a man with 
four testicles alluded to by Blegny.t Blasius, an 
old writer not unworthy of credit, has, however, 
given an account of the examination of the body 

* Eph. Nat. Cur. Dec. iii. Ann. v. vi. Obs. 89. p. 175. 

f Zodiaque Fran9ais, Ann. 11. Most of the reputed cases of Trior- 
chides are quoted by Arnaud in his Memoires de Chirurgie, Mem. iii. 
part 1. 



NUMERICAL EXCESSES AND DEFECTS. 75 

of a man, thirty years of age, and otherwise well 
formed, who had two testicles on the right side, of 
the same size and shape as that on the left, which 
is illustrated by a small engraved figure represent- 
ing a distinct artery from the aorta, and vein from 
the vena cava, proceeding to each of the two testi- 
cles on the right side.^ This is the only case of 
supernumerary testis recorded by the old authors 
which has any semblance of authenticity. Neither 
Morgagni, Haller, nor Meckel met with a single 
example, and they questioned the existence of such 
a condition. The two following are recorded as 
cases of the kind, but they were not verified by 
examination after death : Bliimener, an army sur- 
geon, states in Rust's Magazin fiir die Gesammte 
Heilkunde for 1824, that on examining a recruit, 
a robust peasant twenty years of age, he found on 
the right side of the scrotum a healthy testis, and 
on the left side two. One like that on the right 
side was situated at the bottom of the scrotum ; the 
other, which was smaller, was placed above the 
first and nearer to the abdominal ring, and it had 
its own epididymis and spermatic cord. This testis 
felt as firm and as round as the first, and a similar 
sensation was experienced when it was compressed. 
Dr. Macann, staff surgeon, relates, that on exa- 
mining a recruit, about twenty years of age, a body 
was found on the right side of the scrotum, which 
was so similar to the two testicles in size, form, 
feeling, and consistence, as to leave no doubt of its 

* Ger. Blasius, Obs. Med. Anat. Obs. 20, p. 60. 



76 NUMERICAL EXCESSES AND DEFECTS. 

being a third testicle. This body was situated be- 
tween the groin and the proper testicle of the right 
side, with which, however, it did not seem to be in 
immediate contact, but to be suspended, as it were, 
by a shorter cord, or hung up in a separate sac. 
The right spermatic cord was much thicker than 
natural at its upper part, where, in fact, it con- 
sisted of two cords, one of which was distinctly 
traced into the upper testicle on this side, and the 
other, much longer, into the lower testicle, and in 
each of those parts, as well as in the cord on the 
left side, the vas deferens could be distinctly felt, 
like a piece of whipcord, between the fingers. 
The man stated that the third testicle had occu- 
pied its present situation as long as he could re- 
member, and had never caused him any incon- 
venience.* 

An epiplocele, a fatty or fibrous tumour in the 
scrotum, or an encysted hydrocele of the cord, 
might readily be mistaken for an additional testis. 
Morgagni mentions that he was once deceived by 
a portion of omentum. In the pathological collec- 
tion at St. Thomas's Hospital is preserved the 
testis of the eccentric Dr. Monsey, who appeared 
during life to be supplied with three of these glands. 
The supposed additional testis consists of an indu- 
rated fibrous tumour attached apparently to the 
tunica vaginalis. My friend Professor Fergusson, 
of King's College, has communicated to me the 
particulars of the case of a man aged seventy- 

* Provincial Medical Journal, Nov. 5, 1842, p. 113. 



NUMERICAL EXCESSES AND DEFECTS. 77 

three, who had a tumour in the back part of the 
scrotum, about the size of a walnut, which so 
nearly resembled in shape, position, and size each 
testicle, as to render it difficult to distinguish the 
difference without a manual examination. It was 
removed, and found to be of a fibro-cartilaginous 
texture. It lay in close contact with the tunica 
vaginalis on one side, and in its removal care was 
required to avoid opening that membrane. 

Absence of one or both Testes. — Many instances 
of monorchides, or persons having only a single 
testis, are also mentioned by the old authors ; but 
as the data are very imperfect, and as little was 
known respecting the descent of the testis at the 
time these cases were recorded, they must be 
viewed with great suspicion. They were most 
probably cases in which one of the testes was 
either retained within the abdomen, or from some 
cause had been completely atrophied. I know no 
satisfactory reason why a deficiency of one or both 
testicles should not occasionally occur without any 
other malformation ; but they are anomalies of 
which there are very few authentic examples in 
the annals of medical science. Mr. Paget, Demon- 
strator of Morbid Anatomy at St. Bartholomew's 
Hospital, has published a case in which he believes 
one testis was deficient at birth.* The subject of 
it was a robust man, aged seventy-one, who had 
died of acute inflammation of the oesophagus. The 
scrotum was small, and unusually narrow ; on its 

* London Medical Gazette, vol. xxviii. p. 817. 



78 NUMERICAL EXCESSES AND DEFECTS. 

anterior surface there was no trace of raphe, but 
on its posterior part the raphe of the perineum 
was continued for a short distance. The penis was 
of ordinary dimensions, and the bladder, prostate, 
and vesiculas seminales, were healthy and well 
formed. The left vesicula was rather smaller than 
the right : both contained the usual brownish fluid. 
The right vas deferens, testicle, and parts connected 
with them, differed in no respect from those of 
healthy men. The left vas deferens followed its 
usual course from a healthy ejaculatory duct to 
the internal inguinal ring, where, meeting with the 
other parts of the spermatic cord, it became larger 
and slightly tortuous. After two or three short 
curves, it terminated nearly opposite the external 
ring in a rounded cul-de-sac : it was pervious to its 
very extremity, and its canal was of the ordinary 
diameter. The remainder of the spermatic cord 
passed towards the outer and lower part of the 
left side of the scrotum, and there expanded into a 
small flat mass of an oval form, adhering to the 
surrounding cellular tissue, but clearly defined by 
its rather closer texture. In this part of the sper- 
matic cord there was no trace of an obliterated 
duct : it seemed composed of little more than fine 
cellular tissue ; and in the mass at its extremity 
there was neither a cavity nor any appearance of 
tubules, tunica albuginea, or any other part of a 
testicle. The left spermatic artery was derived 
from the left renal, and passed in its usual direction 
through the inguinal canal ; but it was very small, 
and, not having been injected, it could not be 



NUMERICAL EXCESSES AND DEFECTS. 79 

traced beyond the closed extremity of the vas 
deferens. No account of the man is attached to 
these particulars ; and it is therefore open to ques- 
tion whether the deficiency of the gland was not 
the result of atrophy. Mr. Paget, in some observa- 
tions on this case, very justly attaches considerable 
weight to the absence of any trace of the tunica 
albuginea, and to the fact of the vas deferens ter- 
minating in a rounded cul-de-sac, as the testicle, 
when wasted even in an extreme degree, usually 
preserves some trace of its fibrous envelope, the 
tunica albuginea ; whilst the vas deferens, though 
diminished to a small impervious cord, can gene- 
rally he traced on to the remains of the gland. 
These circumstances, though favourable to his 
view of the case, do not appear to me sufficiently 
conclusive. The fact of a descent having taken 
place, as shown by the remainder of the cord 
passing beyond the cul-de-sac to the lower part of 
the scrotum, and the advanced age of the man 
having allowed time for a more than usual oblite- 
ration of the organ, leave room for question whether 
the testis was originally altogether wanting. The 
case might possibly have been one of congenital 
imperfection in the vas deferens, as described, and 
the testis perhaps being likewise defective, and at 
any rate utterly useless as a secreting organ, might 
after its descent, have undergone a total wasting. 
The case is at least involved in some doubt. 

The following case, recorded by Dr. Fisher of 
Boston,* is perhaps a more satisfactory example of 

* American Journal of the Medical Sciences, vol. xxiii. p. 352. 



80 NUMERICAL EXCESSES AND DEFECTS. 

absence of both testes. The deficiency was re- 
marked from birth, and the perfect descent of the 
parts can be explained, as the cremaster muscle 
was found spread around a tunica vaginalis, and 
the vas deferens, which terminated as in the pre- 
ceding case in a cul-de-sac, passed to the bottom of 
the cord, and must therefore have been connected 
as usual to the gubernaculum. The man was 
supposed to have been born a natural eunuch, and 
he died of pneumonia at the age of forty-five. The 
late Dr. Warren discovered the deficiency of testes 
soon after birth. At puberty the man's voice re- 
mained unchanged; he had no beard or whiskers, 
the skin of the pubes and scrotum was without 
hair, the penis was not larger than that of a boy 
ten or twelve years old, and the scrotum was con- 
tracted in size. On dissection, the skin, dartos, 
and tunica vaginalis were of a natural appearance, 
but no testes existed in the scrotum. The sper- 
matic cord extended into the cavity of the tunica 
vaginalis about half an inch, and terminated ab- 
ruptly in a point of a semilunar shape. It was much 
smaller than usual in adults. The cremaster muscle 
was seen extending in numerous small fibres be- 
yond the terminus of the cord, which spread them- 
selves out upon the tunica vaginalis. The vas de- 
ferens was properly formed, and nearly of natural 
size : its cavity terminated in a cul-de-sac at the 
end of the cord. The arteries and veins were ex- 
ceedingly small, hardly distinguishable. The right 
spermatic cord differed in no respect from the left, 
except that it extended to the bottom of the scro- 



NUMERICAL EXCESSES AND DEFECTS. 81 

turn, and turned upwards a quarter of an incL 
The vesiculce seminales were not examined. This 
man never exhibited any amorous propensities, or 
desire for female society. 

Mr. Thurnam has published an account of the 
dissection of an infant who died at the age of four 
months. In addition to an atrophied condition of 
the right kidney, and a remarkable malformation of 
the ureters, it was found that neither of the testicles 
had descended. The right lay in the abdominal 
cavity, just above the inguinal canal. On the left 
side no testicle would appear to have been formed ; 
the spermatic vessels on this side terminated in a 
little mass of fat ; the vas deferens, however, was 
present, and was apparently as well developed as 
that of the perfect testicle.* A case of monstrosity 
is related by Dr. Friese in Casper's Wochenschrift.t 
The child lived only half an hour : in addition to 
the absence of the external genital organs, there 
were neither testes, vasa deferentia, nor vesiculsg 
seminales. Cases, however, in which the whole 
of the genital apparatus is deficient or irregularly 
formed do not come within the scope of this work. 

[On the 3th of June, 1838, I was called to exa- 
mine the body of a supposed hermaphrodite, and 
found that the subject was a male. The penis was 
about an inch in length externally, and the scrotum 
scarcely perceptible. It contained two bodies, 

'■'■'■ London Medical Gazette, vol. xx. p. 717. 

t Dec. 25, 1841, quoted in the British and Foreign Medical Review 
for April, 1842, p. 527. 

11 



82 NUMERICAL EXCESSES AND DEFECTS. 

which were attached by cords to the external ring. 
They were effete testes, presenting no remains of 
glandular structure, and scarcely any of tunica al- 
buginea. The tunica vaginalis was present, and 
the remains of the vas deferens, spermatic artery 
and vein were visible. His squeaking voice, and 
the total absence of hair on the pubes, indicated 
that their wasting must have taken place in early 
life. The most rational conjecture is, that they 
were destroyed by the metastasis of cynanche pa- 
rotidea during infancy. — Am. Ed.] 

Union of the Testes. — Geoffroy St. Hilaire has 
recorded the following remarkable, and, I believe, 
unique case, of union of the testes in the abdomen. 
It was communicated to him by M. Breton of Gre- 
noble. An infant was born at Vizille in 1812: 
several physicians consulted respecting the child's 
sex were of different opinions ; they decided, how- 
ever, to inscribe it in the registers as a girl. It 
died at the age of eighteen months, and was dis- 
sected by Dr. Breton, who recognised a complete 
hypospadias. The scrotum was bifid and empty ; 
and the two subrenal capsules, as well as the two 
kidneys and the two testicles, were joined together 
upon the median line. The spermatic arteries 
and veins, vesiculas seminales, and vasa deferentia, 
exhibited nothing remarkable, each half of the 
double testicle receiving its particular vessels.^ 

* Hist, des Anomal. de TOrgan, t. i, p. 542. 



DEFICIENCIES AND IMPERFECTIONS, ETC. 83 



SECTION II. 

DEFICIENCIES AND IMPERFECTIONS OF THE VAS DEFERENS. 

In Mr, Paget's case of supposed absence of the 
testis, it is stated that the vas deferens terminated 
nearly opposite the external ring in a rounded cul- 
de-sac ; and in Dr. Fisher's case of deficiency of both 
testes, that the vasa deferentia, though properly 
formed and nearly of natural size, terminated in 
cul-de-sacs at the end of the cord. Mr. Paget 
lately showed me a preparation contained in the 
Museum of St. Bartholomew's Hospital, taken from 
a man fifty years of age who died of strangulated 
hernia.'^ A piece of intestine was strictured by a 
preternatural band of adhesion connected with the 
mesentery, and the testis was detained in the upper 
opening of the ring. On a recent and careful dis- 
section of the parts, the vas deferens was found to 
terminate near the testis in a cul-de-sac. The 
gland was very small ; and its structure appeared 
granular, like the undeveloped testicle of a youth. 
There was no trace of the epididymis. Mr. Hunter, 
in dissecting a male subject for a side view of the 
pelvis, found a bag on the left side lying contigu- 
ous to the peritoneum, just on the side of the pelvis 
where the internal iliac vessels divide above the 
angle of reflection of the peritoneum at the union 
of the bladder and rectum. The left vas deferens 

* The case is related by Mr, Lawrence in his Treatise on Ruptures, 
5th edit. p. 271. 



84 DEFICIENCIES AND IMPERFECTIONS 

was seen passing on to this bag ; and that of the 
right or opposite side crossed the bladder near its 
union with the rectum to join it. He traced the 
left vas deferens down to the testicle ; but, on fol- 
lowing the right through the ring of the external 
oblique muscle, he discovered that it terminated 
at once, about an inch from its passage out of the 
abdomen, in a blunt point, which was impervious. 
On examining the spermatic cord from this point 
to the testicle, he could not find any vas deferens ; 
but by beginning at the testicle, and tracing the 
epididymis from its origin about half way along 
where it lies upon the body of the testicle, he 
perceived that it at first became straight, and soon 
after seemed to terminate in a point. The canal 
at this part was so large as to allow of being filled 
with quicksilver ; which, however, did not pass far, 
so that a portion of the epididymis was wanting, 
and likewise the vas deferens, for nearly the whole 
length of the spermatic cord on the right side. On 
the left side the vas deferens began where the epi- 
didymis commonly terminates, and there was a de- 
ficiency of nearly an inch of the extremity of the 
epididymis. He then dissected the bag above 
mentioned, which proved to be the two vesiculse. 
They contained mucus ; but, upon the most accu- 
rate examination, he could neither discover any 
duct leading from them to the prostate gland, nor 
the remains of one. The caput gallinaginis had 
the common appearance, but there was no orifice 
to be found. The testicles were very sound, and 
the ducts from them to the epididymis were very 



OF THE VAS DEFERENS. 85 

manifest, and contained semen.* In this case it 
appears that the vasa deferentia were not only 
deficient near the testicles, but terminated below 
in a single irregularly-formed vesicula seminalis, 
and had no communication with the urethra. There 
are a few other cases on record in which the vas 
deferens has been defective at the extremity which 
joins the ejaculatory canal. Thus Tenon, in the 
dissection of an infant affected with extroversion 
of the bladder, who died at the age of two months, 
found that the vasa deferentia terminated sepa- 
rately at the bottom of the pelvis in two white 
tubercles : the scrotum, testes, and vesiculce semi- 
nales were in a natural state.t But, besides these 
imperfections at its two extremities, this duct has 
been found wanting throughout nearly its whole 
extent. Brugnone mentions, that in dissecting the 
parts of generation in a robust man, from twenty- 
six to twenty-seven years of age, who died of peri- 
pneumonia, he accidentally found the right epi- 
didymis almost entirely absent ; the only part 
remaining being the head, which formed nodules 
filled with semen. The rest of the epididymis and 
the vas deferens were wanting, without any mark 
of disease. The testis was perfectly sound, and 
nearly of the same size as the left one. On ex- 
amining the corresponding vesicula seminalis, he 
found at its anterior extremity a portion of the 

* Works, by Palmer, vol. iv. p. 23. The parts are figured in Dr. 
Baillie's engravings of Morbid Anatomy, fasc. viii. pi. i. fig. 2. 

f Mem. sur quelques Vices des Voies Urinaires, &c. in Mem. de 
I'Acad. Roy. des Sciences a Paris, 1761, p. 115. 



86 DEFICIENCIES AND IMPERFECTIONS 

canal of the vas deferens about an inch in length 
and properly formed. The vesicula seminalis itself 
was flaccid and quite empty ; whilst the left was 
full of semen. He remarks, that although this 
vicious conformation was, according to all ap- 
pearances, congenital, nevertheless the vesicula 
seminalis and ejaculatory canal had preserved their 
natural cavities.^ In a case related by Bosscha the 
left vas deferens of a robust man terminated in a 
blind extremity near the testicle, the rest of the 
canal being wanting. There was the rudiment of 
a left vesicula seminalis, in the form of a blindly- 
ending canal, running tortuously in the shape of 
the letter S. The left testicle was sound.t 

Mr. Paget has happily explained the origin of 
these several defects in the vas deferens by refe- 
rence to the mode of developement of the special 
organs of generation. He observes,^ after Midler 
and Valentin, that, in the normal course of human 
developement, the proper genital organs are in 
either sex developed in two distinct pieces : namely, 
the part for the formation of the generative sub- 
stance, the testicle or ovary, and the part for the 
conveyance of that substance out of the body, the 
seminal or oviduct. The testicle or ovary, as the 
case may be (and in their earliest periods they 
cannot be distinguished), is formed on the inner 

* Observ. Anat. sur les Vesicules Seminales, Mem. de I'Acad. Roy. 
des Sciences a Turin, 1786-7, p. 625. 

■\ Diss, sistens Obs. de Vesiculee Seminalis sinistrsB Defectu, inte- 
gris testibus, vase vero deferente clause, quoted by Dr. Vrolik, Hand- 
boek der Ontleedkundige Ziektekunde, 1st Deel. p. 210. 

I Loc. cit. p. 818. 



OF THE VAS DEFERENS. 87 

concave side of the corpus Wolffianum ; and the 
seminal or oviduct, which is originally an isolated 
tube closed at both extremities, passes along the 
outer border of that body, from the level of the for- 
mative organ above to the cloaca or common sinus 
of the urinary, genital, and digestive systems below. 
The perfection of developement is attained only by 
the conducting tube acquiring its just connexions at 
once with the formative organ, and, through the 
medium of the cloaca, with the exterior of the 
body. The sexual character is first established, 
when, in the male, the formative and conducting 
organs become connected by the developement of 
intermediate tubes which constitute the epididymis; 
or when, in the female, a simple aperture is formed 
at the upper extremity of the conducting tube, and 
is placed closely adjacent to the formative organ. 
In both sexes alike, the lower extremities of the 
conducting tubes first open into the common cloaca, 
and subsequently, when that cavity is partitioned 
into bladder and rectum, or bladder, vagina, and 
rectum, they acquire in each their just connexions, 
and become in the male the perfect vasa deferentia, 
and in the female the Fallopian tubes and uterus. 
Now in Brugnone's case, and in Bosscha's, we 
have examples of one of the male conducting tubes 
being developed in only a very small portion of its 
natural extent. These, therefore, clearly confirm 
the description just given ; for they prove that the 
testes may be formed quite independently of the 
vasa deferentia. In the other cases the vas defe- 
rens was probably formed originally in its whole 



88 DEFICIENCIES AND IMPERFECTIONS 

length ; but it seems to have failed of acquiring its 
due connexion in the one series of defects at the 
end next to the testicle, and in the other at the end 
next to the bladder. 

Mr. Paget adds, that the cases by Hunter and 
Brugnone illustrate, in some measure, the mode of 
formation of the epididymis. In the former case 
the epididymis of the right side, " about half way 
along where it lies on the body of the testicle, at 
first became straight, and soon after seemed to ter- 
minate in a point ;" and of that of the left side 
nearly an inch of the lower part was deficient. In 
the latter case " the right epididymis was almost 
entirely wanting ; there was nothing but the head 
of it, which formed a number of tubules filled with 
semen." MiAller says that the coni vasculosi are 
formed by the developement of a substance inter- 
mediate between the upper end of the primitive 
simple vas deferens and the testis, and that the 
body of the epididymis is produced by the mere 
growth and convolution of the vas deferens. These 
cases on the whole, confirm his account ; but they 
prove also that a part of the body of the epidi- 
dymis may be formed by the growth of tube from 
the side of the testis alone, for in all of them there 
was more of the epididymis than is formed by the 
coni vasculosi. 

The inquiry is not without interest, — What in- 
fluence have these deficiencies and imperfections in 
the vas deferens on the evolution and subsequent 
condition of the testis ? In the case of the adult 
which occurred at St. Bartholomew's Hospital the 



OF THE VAS DEFERENS. 89 

testis was small, and its structure appeared gra- 
nular, like the undeveloped testis of a youth ; but 
as it had not descended into the scrotum, and was 
combined with hernia, there may have been other 
causes impeding its due evolution. In Mr. Hunter's 
case, the testicles which were in the scrotum were 
very sound. In the case of the man related by 
Brugnone the testis on the side corresponding to 
the defective vas deferens was perfectly sound, and 
nearly of the same size as the other. So also in 
Bosscha's case it is stated that the testis was 
sound. Although either of these defects in the vas 
deferens renders the gland an useless organ, and if 
it occurred on both sides of the body would neces- 
sarily cause impotency, these cases, nevertheless, 
tend to show that the absence or imperfection of 
the excretory duct does not prevent the develope- 
ment of the testis at the proper period, and has no 
direct influence in causing it to waste, and these 
inferences are fully confirmed by experiments on 
animals. Sir A. Cooper relates, that in 1823 he 
divided, upon a dog, the vas deferens upon one 
side, and the spermatic artery and vein on the other. 
The testis upon that side on which the artery and 
vein were divided gangrened, and sloughed away. 
The testis on the other side became somewhat 
larger than natural. He kept the dog for six years ; 
during that time he was twice seen in coitu, but the 
female did not produce. This was in 1827. In 
1829 he killed the dog, and found the vas deferens 
below the division excessively enlarged, and full of 
semen, and entirely stopped, with some separation 

12 



90 DEFICIENCIES AJND IMPERFECTIONS 

of its extremities; but it was open from the place 
of division to the urethra.^ — February 23d, 1842, 1 
divided the vas deferens and a small artery running 
close to it (not the spermatic) on the left side, and 
excised a small piece of the vas deferens on the 
right. The dog afterwards evinced a partiality for 
a bitch in a neighbouring house. He was killed the 
26th of April following. The abdominal aorta was 
injected. The right testis was healthy, and of good 
size ; its epididymis was hard, and clogged with a 
thick white substance which contained abundance 
of spermatozoa. The divided ends of the ducts 
were separated and closed. The right spermatic 
artery was of its normal size. The left testis was 
atrophied, and presented no trace of its natural 
structure. The parts composing the cord were 
matted together, and extremely indistinct at the 
point where the vas deferens had been divided. 
This duct was reduced to a mere cord. The left 
spermatic artery appeared obliterated, for no injec- 
tion had passed into it, and the vessel was scarcely 
perceptible. These changes on the left side, I sus- 
pect, were the result of inflammation induced by 
the operation. — April 9th, 1842, in a young bull 
terrier I excised a small portion of the vas deferens 
on the left side, and on the right tied a ligature 
tightly round all the parts composing the cord, 
except the vas deferens, and divided the included 
parts below the ligature. The dog was killed on 



* Anatomy of the Testis, p. 51. The testis is represented in the 
plate of full size. 



OF THE VAS DEFERENS. 91 

the 25th of June following. The left testis was of 
its natural size, and contained spermatozoa. The 
right testis was completely atrophied, a small epi- 
didymis attached to the end of the vas deferens 
being all that remained of the gland. — April 26th, 
1842, in a large young dog, whose testicles had not 
acquired their full size, I exposed the cord, and 
made a simple division of the vas deferens on the 
left side. The dog was killed on the 25th of June 
following. The two testes were exactly of the 
same size, but the left was loaded with fluid con- 
taining spermatozoa. The ends of the divided vas 
deferens were separated and closed. — June 29th, 
1842, in a kitten eight weeks old I divided the vas 
deferens on each side, and separated the cut ex- 
tremities of the ducts. He grew a remarkably fine 
cat ; and in the following February became restive 
and noisy, and evinced a disposition to rove from 
the house. On the 24th of the month I excised 
the testes. They were plump, and filled with fluid 
which was found to contain abundance of lively 
spermatozoa. 

The foregoing cases and experiments show, then, 
that the testes may be properly developed, though 
a physical obstacle to the elimination of their se- 
cretion is present from birth ; and that so long as 
the testicles exist entire, though to no purpose, the 
individual acquires and preserves all the marks of 
the male sex, the secreting organs of generation 
alone appearing to be the speciality upon which the 
sexual characters depend. The engorgement of 
the seminal ducts with sperm is liable, it is true, to 



92 IMPERFECT DESCENT OF THE TESTIS. 

cause inflammation of the testis, which may end in 
atrophy, but this is only a secondary and occasional 
effect of the interruption in the excretory duct. 



SECTION III. 

IMPERFECT DESCENT OF THE TESTIS. 

It occasionally happens that at birth one or both 
testes have not passed into the scrotum, being 
detained either in the abdomen near the internal 
ring, in the inguinal canal, or in the groin just 
outside the external ring. In a table of one hun- 
dred and three male infants examined by Wrisberg 
at the time of birth, it appears that seventy-three 
had both testes in the scrotum ; in twenty-one, 
one or both were in the groin ; of these, five had 
both, seven the right, and nine the left in the groin ; 
in twelve, four had both, three the right, five the 
left, only in the abdomen.* According to this 
table the imperfection occurs rather more fre- 
quently on the left side than on the right, in the 
proportion of seven to five. In twenty cases exa- 
mined, at different ages varying from five to sixty, 
eleven of which came under my own observation, 
the remainder being taken from the recorded ex- 
perience of others, in ten the imperfection was on 
the left side, and in the same number on the right. 
Dr. Marshall states that in the examination of 
10,800 recruits he had found five in whom the 

* Commentatio Soc. Reg. Scient. Goetting. 1779. 



IMPERFECT DESCENT OF THE TESTIS. 93 

right, and six in whom the left testicle was not 
apparent. In two of these cases there was inguinal 
hernia at the side where the testicle had not de- 
scended."^ He met with but one instance in which 
both testicles had not appeared.f The testis some- 
times remains permanently fixed in the situation 
in which it is placed at birth :J but in many in- 
stances the passage, though delayed, is completed 
at some period previous to puberty, and often 
within a few weeks after birth. Mr. Hunter was 
of opinion that this completion most frequently 
happens between the years of two and ten.§ Of 
the twelve cases mentioned by Wrisberg, in which 
one or both testes were retained in the abdomen, 
in one the descent took place the day of birth, in 
three on the day after, in three others on the third 
day, in two instances on the fifth day, and in one 
on the twenty-first day: in the other cases, the- 
testes had not appeared at the fourth or fifth week 
after parturition. || My own observations lead me 
to believe that if the descent does not take place 
within a twelvemonth after birth, it is rarely or 
never afterwards fully and perfectly completed 
without being accompanied with rupture. For 
the causes which operate at this late period tend 
as much to promote the formation of hernia as the 
descent of the testis. In cases where the testis 



* Hints to Young Medical Officers in the Army, p. 83. 
t Ibid. p. 207. 

I Persons whose testicles had not descended were called upv^'Opx^^^f} 
or testicondi, by the ancients. 

6 Lib. cit. p. 15. 1| Ibid. p. 203. 



94 IMPERFECT DESCENT OF THE TESTIS. 

makes no appearance before puberty, uneasiness 
is often experienced at that period, owing to the 
enlargement of the gland being restrained by the 
rings and parts composing the inguinal canal. At 
the same time, also, it is often protruded outside 
the external ring by the movements of the abdomen 
in respiration. 

The causes of a failure in the descent of the testis 
have not been much investigated; and as considera- 
ble doubt has long prevailed respecting the mode 
and agency by which this change is effected, no 
satisfactory explanation could be expected of the 
^circumstances interrupting or preventing it. When 
we reflect on the nature of that process, as my 
researches have led me to describe it, it is clear 
that there must not only be a perfect adaptation 
of parts, a due relation between the body drawn 
down, and the structures which it traverses, but 
also corresponding power in the agent by which it 
is accomplished. There are few muscles in the 
human body whose developement in different indi- 
viduals varies in a greater degree than that of 
the cremaster. And if such be the case after birth, 
it is not unreasonable to presume that similar dif- 
ferences exist in the foetus before the descent of 
the gland, and that a failure in that process may 
be the result of deficient power in the musculus 
testis to accomplish the passage. May we not also 
conclude that this muscle is sometimes paralyzed, 
and that the faulty descent is owing to a want of 
a due supply of the nervous energy which we know 
is often denied to other muscles during foetal ex- 



IMPERFECT DESCENT OF THE TESTIS. 95 

istence, and is the cause of deformities in the feet 
and other parts with which infants are often 
ushered into the world ? I think, indeed, we may 
fairly enumerate paralysis and defective develope- 
ment of the cremaster amongst the causes of the 
imperfect descent of the testis. 

Peritonitis occasionally attacks the foetus in 
utero,* and produces adhesions between the various 
abdominal viscera. It is well known, that in con- 
genital hernia the testis is frequently united to a 
portion of intestine or omentum, and that the for- 
mation of these adhesions, previous to the testi- 
cular descent, is sometimes the cause of the dis- 
placement, the viscera being drawn down together 
with the gland into the scrotum. Many facts seem 
to show that similar adhesions are, on the other hand, 
an occasional cause of the temporary and perma- 
nent retention of the testicle, the cremaster being 
insufficient to overcome this obstacle to its descent. 
In the body of an old man, M. J. Cloquet found the 
left side of the scrotum empty and the testicle 
situated at the distance of an inch from the supe- 
rior opening of the inguinal canal : the head of the 
epididymis was connected to the sigmoid flexure 
of the colon by a strong white fibrous band.t 
Wrisberg states, that on examining an infant which 
had only the right testicle in the scrotum, and died 
a few days after birth, he found the opposite gland 

* Vide contributions to Intra-uterine Pathology by Dr. Simpson, 
Edinb. Med. and Surg. Journal, Nos. cxxxvii. and cxl. 

t Recherches sur les Causes et I'Anatoraie des Hernies Abdomi- 
nales, p. 24. 



96 IMPERFECT DESCENT OF THE TESTIS. 

close to the ring and connected to the omentum by 
means of three slender filaments.^ Dr. Simpson, 
in the dissection of an anencephalic foetus found 
marks of extensive peritonitis and the right testicle 
imbedded in a quantity of coagulable lymph, which 
strongly attached it to the peritoneal surface of 
the iliac fossa.t Jobert remarks, that he once 
found in the fa3tus the coecum adherent to the tes- 
ticle, which was on the point of passing the ring.J 
In the examination of a man aged sixty, who died 
in the London Hospital, of phthisis, I found the 
right testis just external to the abdominal ring ; it 
was small in size and closely adherent to a portion 
of omentum. A young man, aged nineteen, has 
been under my care the last twelve months, on ac- 
count of an imperfect descent of the testis on the 
left side. The gland plays backwards and forwards 
through the external abdominal ring. By pressure 
above, it can be forced down sufficiently to admit 
of being examined. This testis is much smaller 
than the right, which is in the scrotum, and I can 
distinctly make out a portion of intestine closely 
adherent, which accompanies it in all its move- 
ments. 

Mr. Hunter remarks, that the part where the 
testis meets with the greatest difficulty in its de- 
scent is in the division of the tendon of the external 



* Lib. cit. p. 229. 

f Edinb. Med. and Surg, Journal, No. cxc. p. 27. 
I Traite des Maladies Chirurgicales du Canal Intestinal, t. 
p. 332. 



IMPERFECT DESCENT OF THE TESTIS. 97 

oblique muscle called the ring.* It is probable 
that the smallness of this opening is sometimes, 
also, a cause of the detention of the testis, espe- 
cially in those cases in which the organ is retained 
within the inguinal canal. Mr. Wilson, an accu- 
rate anatomist, was of this opinion,! which is sup- 
ported by the fact, that the testis is oftener found 
in the groin than in the cavity of the abdomen. 
M. Delasiauve mentions a case in which he states 
the organ was retained by the border of the outer 
column of the ring.J 

Mr. Hunter was inclined to suspect that the 
fault originates in the testicles themselves. It is 
difficult to understand how this can be, for as the 
gland is passive in this process, it can offer no 
obstacle, unless it grows too large to pass the open- 
ing in the abdominal parietes ; whereas, it is ad- 
mitted that the gland when retained is usually 
below the natural size. Nor does it appear, that 
the interruption is owing to any want of proper 
length in the vas deferens, for in a case of imper- 
fect descent in a boy, whose body I examined, I 
particularly noticed that this duct was so long as 
to be doubled on itself and tortuous, a circumstance 
which has been remarked in other cases by Mr. 
Mayo,§ Rosenmerkel,|| and others. It may be con- 
cluded then, that the causes of a failure in the de- 



* Lib. cit. p. 16. 

t Lectures on the Urinary and Genital Organs, p. 405. 

\ Revue Medicale, Mars, 1840, p. 363. 

$ Human Physiolog-y, 3d edit. p. 411. ' 

II Ueber die Radicalcur des in der Weiche liegenden Testikels. 

13 



98 IMPERFECT DESCENT OF THE TESTIS. 

scent of the testis are various ; that this imperfec- 
tion may result from want of power or paralysis of 
the cremaster muscle, from adhesions retaining the 
gland within the abdomen, and from a contracted 
state of the opening of the external abdominal ring. 
Oil the Condition of the undescended Testis. — 
Mr. Hunter states that when one or both testicles 
remain through life in the belly, he believes that 
they are exceedingly imperfect, and probably in- 
capable of performing their natural functions ; and 
that this imperfection prevents the disposition for 
descent taking place. That they are more defec- 
tive even than those which are late in passing to 
the scrotum, he infers from the circumstance that 
in quadrupeds the testicle that has reached the 
scrotum is considerably larger than the one which 
remains in the abdomen. Mr. Hunter had seen only 
one case in the human subject where both testes 
continued in the abdomen, but this proved an ex- 
ception to the above observation, since we are led 
to conclude that they were perfectly formed, as the 
person had all the powers and passions of a man. 
Mr. Owen, in commenting upon these observations, 
states, " It seems remarkable that with this ex- 
perience Mr. Hunter should have formed from in- 
conclusive analogy, and promulgated an opinion 
tending to occasion so much unhappiness, as that 
which attributes exceeding imperfection and pro- 
bable incapacity of performing their natural func- 
tions to testes which in the human subject are 
retained within the abdomen. That there is 
nothing in such a situation which necessarily tends 



IMPERFECT DESCENT OF THE TESTIS. 99 

to impair their efficiency is evident, from the num- 
ber of animals in which they constantly form part 
of the abdominal viscera ; and in those in which 
the testes naturally pass into a scrotum, their con- 
tinuance in the abdomen, according to our author's 
own observation, is accompanied only with a dif- 
ference of size or shape : now we may readily 
suppose that this may influence the quantity, but 
not necessarily the quality of the secretion."* 

There are very few accounts on record of the dis- 
section of undescended testes ; and it is much to be 
regretted that the gland, when found in the abdo- 
men or groin, has not oftener been subjected to a 
particular anatomical examination. In a case 
alluded to at page 96, in which M. Cloquet found 
the left testis situated within the abdomen, the 
gland was well formed, and of the same size as the 
right, which had descended into the scrotum. The 
parts taken from a young man, an apprentice of 
Sir A. Cooper, who unfortunately committed suicide 
in consequence of the infirmity, are preserved in 
the Museum of Guy's Hospital. I have examined 
the preparation ; and the testes, which are both 
within the abdomen, close to the internal ring, ap- 
pear to be nearly, if not quite, the natural size, and 
it is stated that the ducts contained semen. In a 
lad aged 19, whose left testis was found by Dr. 
Bright within the abdomen, near the brim of the 
pelvis, the gland was considerably smaller than 
natural, but the ducts and secreting structure were 

* Works by Palmer, vol. iv. p. 18. 



100 IMPERFECT DESCENT OF THE TESTIS. 

quite perfect.^ These are the only cases of testes 
situated within the abdomen, in which we have any 
account of the anatomical condition of the gland. 
In addition to the evidence they afford of the capa- 
bility of testes thus placed to exercise their func- 
tions may be adduced the case of Mr. Hunter, just 
alluded to, in which a person, both of whose testes 
continued in the abdomen, had all the powers and 
passions of a man. On the other hand, Mr. Wil- 
son mentions the case of a young man, twenty-five 
years of age, whose testes never descended. He 
had some beard, and not an unmanly appearance ; 
but although an imprudent, and in some things a 
dissipated person, he had never shown the least 
desire for women, or disposition for sexual inter- 
course.t — John West, a lad aged 16, died in the 
physician's wards of the London Hospital, in a state 
of universal anasarca. The lungs were compressed 
by a large quantity of fluid on both sides of the 
chest, and the liver was extremely large. There was 
no appearance of beard, and only a few hairs were 
scattered over the pubes. My attention was par- 
ticularly directed to the state of the genital organs, 
by observing that the scrotum, which was greatly 
distended with serous effusion, was not fully de- 
veloped on the right side. I found the right testis 
within the abdomen, situated about an inch and a 
half above the internal ring. It was very small, 
not larger than that of a child two years of age, 



* Hospital Reports, vol. ii. p. 258. 

t Lectures on the Urinary and Genital Organs, p. 408. 



m 



IMPERFECT DESCENT OF THE TESTIS. 101 

and on cutting into it the gland presented the 
granular appearance usually remarked at that early 
period. The coecum and its appendix were close to 
the testis, the vermiform process being connected to 
the part where the gland was detained by a small 
duplicature of peritoneum. A firm fibrous cord 
was connected to the lower part of the epididymis, 
and passing down through the inguinal canal ter- 
minated in the bottom of the scrotum, becoming 
less distinct in its descent. This was evidently the 
remains of the gubernaculum. The left testis, 
which was in the scrotum, was four times the size 
of the right. The vasa deferentia and vesiculae 
seminales were sound, and of corresponding size. 

It is not particularly stated in Mr. Wilson's case 
whether the testes were detained in the abdomen or 
in the inguinal canal : but assuming that they had 
not passed out of that cavity, as far as 1 can ascer- 
tain this is a solitary case of impotency occurring 
under such circumstances ; and when we consider 
how various are the causes of defective sexual 
power, this single instance, and the case of West, 
which I have just related, are scarcely sufiicient to 
confirm the opinion of Mr. Hunter, or to invalidate 
the general conclusion, that retention of the testes 
in the abdom.en does not incapacitate them from 
performing their proper functions, a point on which 
it is obviously of great importance that surgeons 
should have it in their power to give a confident 
and satisfactory opinion, and relieve the anxiety of 
parents. At the adult period of life, the external 
characters of the body distinguishing the sex, and 



102 IMPERFECT DESCENT OF THE TESTIS. 

the habits and disposition of the individual, will 
always materially assist in enabling the surgeon 
to arrive at a correct conclusion as to the efficiency 
of the organs when internal. 

M. Cloquet gives the following account of a testis 
found in the left inguinal canal, of a subject forty 
years of age. It was flattened, elongated, and in a 
state of atrophy, and so small that it could not be 
felt externally. The epididymis was situated an inch 
below the testis, with which it communicated by fine 
white transparent vessels, running parallel to each 
other, and formed by the seminiferous tubes, un- 
ravelled and drawn out. The vas deferens came off 
from the lower part of the epididymis and entered 
the inguinal canal, where it passed by the side of, 
and internal to, the testis. The testis was situated in 
a hernial sac, which likewise contained omentum."* 
On inspecting the body of a man who died in the 
London Hospital of phthisis and aneurism of the 
aorta, at the age of forty-two, I found the left testis 
situated just outside the external ring. It was but 
little more than half the usual size, and surrounded 
by a tunica vaginalis, adherent in several places. 
On careful examination, no trace whatever of tubuli 
seminiferi could be detected, their place being 
supplied by a white but rather loose fibrous tissue. 
The epididymis was reduced to a few fibrous bands, 
and the vas deferens was small in size ; and on its 
being injected with quicksilver the metal passed no 
further than the commencement of the epididymis. 

* Lib. cit. p., 23. pi. vii. figs. 2 and 3. 



IMPERFECT DESCENT OF TifE TESTIS. 103 

The other testis, which was situated in the scrotum, 
was of less than the average size, and the tunica 
vaginalis was continued for about three inches 
along the cord, but the structure of the gland was 
normal, and the tubuli were distinctly seen. In 
the case of an old man already referred to, and in 
another case of a middle-aged man, who also died 
of phthisis, in each of which one testis was situated 
just outside the external abdominal ring, the organ 
was found atrophied, but unfortunately in neither 
of these cases, which were examined before my 
attention was particularly directed to the pathology 
of the testis, have I preserved a more particular 
account of the state of the glands. Palletta ex- 
amined the body of a man aged about fifty, who 
was supposed to be a monorchis. The spermatic 
vessels on the left side, as they approached the 
pelvis, gradually disappeared, a white transparent 
process alone remaining, which extended beyond 
the ring. The vas deferens, which was hollow 
near the ring, degenerated into a solid compact 
filament, which united to the remains of the sper- 
matic vessels, and terminated outside the ring in 
dense cellular tissue near the os pubis, and con- 
nected to Fallopius's ligament. This cellular tissue 
sustained a series of threads of a light yellow 
colour, but not contained in any proper membrane, 
which might be considered as the remains of the 
testis, although the seminal vessels and vas deferens 
could not be distinctly traced to it.^ 

* Nova Gubernaculi Testis, &c. p. 112. 



104 IMPERFECT DESCENT OF THE TESTIS. 

As far as may be judged from these dissections, 
the testis is more frequently found imperfect and 
atrophied when arrested in the inguinal canal than 
when confined within the abdomen. That such 
should be the case is not surprising. It has been 
seen that there is nothing in the situation of the 
testis in the abdomen calculated to impair its effi- 
ciency, and that its detention there may be owing 
to causes independent of its state of developement. 
No uneasiness or inconvenience is experienced, nor 
are the generative functions interfered with under 
these circumstances. When, however, the descent 
of the testis is interrupted in the inguinal canal, 
the case is very different. The organ is then liable 
to be compressed during any violent action of the 
abdominal muscles, and even in acute flexion of the 
thigh, as in walking up stairs, and on bending the 
body forwards whilst in the sitting posture. It is 
exposed to injury from blows which, being fixed, 
it is unable to elude, and to pressure from the fre- 
quent manipulation of the surgeon, and the ruder 
handling of bandage-makers, and often through 
ignorance, from the application of a truss. It 
occasionally happens that a testis, after retention 
in the abdomen, without any uneasiness having 
been experienced, passes into the inguinal canal, 
and sometimes appears at the external ring, playing 
backwards and forwards from one situation to an- 
other. When this is the case, the gland is liable to 
be caught at some particular part by a sudden con- 
traction or spasm of the abdominal muscles, which 
gives rise to violent pain and suffering, and a sick- 



IMPERFECT DESCENT OF THE TESTIS. 105 

ening sensation which lasts for some hours unless 
relieved by the hot bath, fomentations, and opiates. 
Richter relates the following case: — " I remember 
a young man twenty years of age, who had a small 
hernia, and no testicle on the left side of the scro- 
tum. The testicle was contained in the abdomen, 
and sometimes presented at the ring, causing violent 
pain and symptoms of strangulation, which rendered 
it necessary to push the gland back again. This 
object, however, could seldom be accomplished 
until more than twenty-four hours had elapsed, 
and emollient cataplasms had been employed. The 
symptoms immediately ceased when the return of 
the testis was effected."^ 

We perceive, then, that when a testis is retained 
in the groin, there are various circumstances which 
tend to interfere with its evolution at puberty, to 
impede its nutrition and to excite inflammation and 
disease in it, and we find from dissection that such 
results are very liable to follow. A testis, therefore, 
situated in the abdomen is in a more satisfactory 
position, and is much less exposed to injury and 
disease, than one which has been arrested in the 
groin. On this account, and as the descent is sel- 
dom perfectly accomplished when delayed beyond 
the age of ten or twelve, I think it becomes a 
serious consideration in cases where the gland does 
not make its appearance till this late period, whether 
the well-being of the patient would not be best 
consulted by our employing some mechanical means 

* Quoted in Lawrence on Hernia, 5th edit. p. 571. 
14 



106 IMPERFECT DESCENT OF THE TESTIS. 

to prevent the escape of the organ from the ab- 
domen. A strong reason for adopting this practice 
is afforded by the great liability to rupture, which 
exists in all cases of the tardy descent of this organ, 
owing to the persistence of a sac ready prepared 
for the reception of a protrusion, and in many 
instances to adhesions between the testis and in- 
testine or omentum. A hernia may occur whilst 
the testis is still in the abdomen, or after it has 
passed the ring, and the viscera may descend into 
the scrotum, the gland being detained in the groin. 
Cases of this kind are very embarrassing, as it is 
seldom practicable to fulfil the two opposite indi- 
cations of preventing the protrusion of the viscera, 
and encouraging the descent of the testis. Some 
years ago, I had under my care a fine child, neither 
of whose testes had made their appearance out of 
the abdomen. When I first saw him, he was about 
a year old, and had an inguinal rupture on both 
sides, which descended whenever he cried or strug- 
gled. In accordance with the usual practice, I 
objected to the application of any truss. The 
parents became anxious and impatient at the an- 
noyance arising from the hernia, and consulted a 
high authority, who gave similar advice to that 
received from me. The rupture was consequently 
left to itself and the boy restrained from exercise. 
He was petted, became fretful, and proved a con- 
stant cause of uneasiness to the parents. When I 
last saw him he was eight years of age, and for- 
tunately the rupture on the right side had disap- 
peared spontaneously, and the one on the left 
protruded very slightly, but there was no appear- 



IMPERFECT DESCENT OF THE TESTIS. 107 

ance of the testes. Now, if it be granted that a 
testis situated in the abdomen is in a better position 
than one placed in the groin ; that it is productive 
of less inconvenience, and exposed to fewer causes 
tending to impair its structure ; that its subsequent 
descent, if it ever takes place, is frequently, if not 
commonly attended with rupture, it must, I imagine, 
likewise be admitted, that the advice usually given 
in these cases is unsound and injudicious. Had a 
different practice been adopted in the case of the 
boy just described, and a truss applied, I cannot 
but think that it would have contributed much 
more to his health and comfort than leaving him for 
several years subject to all the inconveniences and 
dangers of an unrestrained double rupture. It 
must not, however, be inferred, that the arrival of 
the testis in the scrotum is a matter of slight im- 
portance, for in all cases of imperfect descent, 
whether the gland be arrested in the abdomen or 
groin, it is nearly always small in size ; and it can- 
not be doubted, that the natural situation of the 
testis is the one best adapted for the efficient per- 
formance of its functions. Besides, the mind is 
very readily disturbed by any appearance of im- 
perfection in the organs of generation, and the 
circumstance of the testes not having descended, is 
very liable to excite suspicion of impotency. I 
have already alluded (page 99) to an instance in 
which the unfortunate subject of this infirmity, a 
medical student, committed suicide under such an 
impression ; still, when there is no reasonable hope 
of the descent into the scrotum being fully and 



108 IMPERFECT DESCENT OF THE TESTIS. 

completely accomplished, and when the patient is 
exposed to the serious inconveniences of hernia, 
feelings, which can generally be controlled by reason 
and judicious counsel, ought not to be indulged at 
the expense of the body. The surgeon may con- 
fidently assure his patient that the detention of 
the testes in the abdomen is perfectly compatible 
with his virility, and in cases where there are no 
external marks of effeminacy or other grounds for 
suspecting impotency, and the patient is subject to 
erections, I should not consider the imperfection 
as offering any bar to marriage. It occasionally 
happens, that a testis descends into the upper part 
of the scrotum accompanied with a reducible hernia 
without adhesion to the gland. In such a case the 
rupture may be reduced without the testis, and 
admit of the application of a truss, which serves 
the double purpose of preventing the hernial pro- 
trusion and preventing the testis from reascending. 
Cases, however, in which this practice can be 
adopted are very rare, for frequently the rupture 
cannot be returned without the testis, and, in many 
cases, it is impossible to apply the truss without 
painful pressure being made upon the gland.* 



* The descent of the testis into the scrotum has heen regarded as 
of such great importance, that in Germany operations have been pro- 
posed, and even practised, for the purpose of placing the gland in that 
situation. Rosenmerkel relates the following case, in which this 
proceeding was adopted. The patient was a man aged twenty-six, and 
the testis first made its appearance in the groin at the age of sixteen ; 
it disappeared and did not trouble him when at rest, but he suffered 
so much pain from it on taking exercise that he was obliged to forego 
all active exertion. He was admitted into the hospital at Munich on 



IMPERFECT DESCENT OF THE TESTIS. 109 

Mr. Pott also justly remarks, in regard to the 
imperfect descent of the testis, " I do not know any 
particular inconvenience arising from the detention 
of a testicle within the cavity of the belly ; but the 
lodgment of it in the groin not only renders it 
liable to be hurt by accidental pressure, &c., but, 
when it is so hurt, may be the cause of its being 
mistaken for a different disease, and thereby occa- 
sion its being very improperly treated. To which 
considerations this may be added, that there is no 
kind of disease to which the testicle is liable in its 
natural situation, but what may also affect it in 
any or all its unnatural ones."^ The detention of 
the testis in the groin or abdomen must certainly 
be regarded as an unfortunate infirmity, and it 
particularly becomes so when the gland is attacked 
with disease. One great disadvantage of an im- 
perfect descent, which especially attaches to the 

account of a chronic affection of the throat, and on his recovery Pro- 
fessor Koch proposed to him to undergo an operation for the relief of 
the testis, to which he readily assented. The skin over the testis 
having been pinched up into a transverse fold, an incision vi^as made 
from the gland in the groin to the bottom of the scrotum. The parts 
beneath were next carefully divided upon a director, until a slight 
fluctuation was detected ; a small opening was made in the tunica 
vaginalis, and about an ounce of serum discharged. The testis was 
found of considerable size, but soft. On drawing the gland from its 
position in the inguinal canal, the cord was found convoluted and 
varicose. The testis was then placed in a cavity in the scrotum pre- 
pared to receive it, and secured there by a suture attached to the 
septum, to prevent the gland being drawn up by the action of the 
cremaster muscle. The wound was afterwards closed with sutures. 
The testis showed a disposition to return to its former position, and 
the cure proved tedious. Lib. cit. 
* Chirurgical Works, 4to. edit. p. 352. 



1 10 IMPERFECT DESCENT OF THE TESTIS. 

detention of the testis in the abdomen, was over- 
looked by Mr. Pott. It arises from the relation 
preserved with the peritoneal cavity, by which 
morbid actions originating in the testis are liable 
to extend to the parts in the abdomen ; and I can- 
not but view the descent of this gland into the 
scrotum, and the isolation of its serous investment, 
as a wise provision, obviating the serious risks to 
which man would otherwise be liable, owing to the 
frequency of the diseases of this organ. It will be 
shown in subsequent chapters that secondary orchi- 
tis, or inflammation, commencing in the epididymis, 
is peculiarly liable to extend to the tunica vaginalis, 
and that in all diseases of the organ this membrane 
is very commonly implicated. Now when the tes- 
tis is situated in the abdomen, or in the groin, and 
surrounded by a prolongation of peritoneum, there 
is no shut sac, no distinct tunica vaginalis, restrict- 
ing the limits of inflammation when set up, but the 
disease is liable to affect the contiguous viscera and 
to extend throughout the abdominal cavity. Such 
appears to have happened in the following cases : 
A lad, ten years of age, was admitted into the 
London Hospital from a distance in the country, 
dangerously ill. His mother, who came with him, 
stated that on returning from school four days be- 
fore, he was kicked in the right groin by one of his 
schoolfellows. He suffered great pain at the time, 
and on the following day became very ill. Having 
continued to get worse, he was brought to the 
hospital. The boy was evidently seriously ill from 
the effects of acute peritonitis. He was almost in 



IMPERFECT DESCENT OF THE TESTIS. Ill 

a state of collapse ; his countenance was anxious ; 
his pulse quick, small, and feeble ; his abdomen 
hot, tumid, and extremely tender ; and his bowels 
constipated, but they had been opened since the 
accident. There was a considerable diffused swell- 
ing in the right groin, and the right side of the 
scrotum was empty. The boy's state was such, 
that no active means could be taken to relieve him, 
and he died in twelve hours after his arrival at the 
hospital. On examination of the body, marks of 
extensive peritonitis were found throughout the 
whole of the abdominal cavity, the viscera being 
coated with lymph, and a turbid serum abundantly 
effused. In the right iliac fossa, just beneath the 
peritoneum, were seen two small abscesses of re- 
cent formation. An atrophied testis was discovered 
close to the external ring, amongst a mass of cellu- 
lar tissue, infiltrated with pus and lymph. There 
were indistinct traces of a tunica vaginalis continu- 
ous with the peritoneum. I apprehend that, in this 
case, the blow occasioned inflammation in the tes- 
tis and surrounding parts, which, extending to the 
peritoneum, caused the patient's death. — 1 was 
summoned one evening to the hospital to see a 
patient of Mr. Luke's, who was supposed to have 
strangulated hernia. On my arrival I found the 
patient, a stout labourer, aged 33, and a married 
man, with a considerable swelling in the right groin, 
which was of an oval form, received a slight im- 
pulse on coughing, and was more solid and tender 
than is usually the case with a rupture. The house 
pupils had made unsuccessful attempts to reduce 



112 IMPERFECT DESCENT OF THE TESTIS. 

the swelling, which gave the man much pain. He 
stated that he was subject to a swelling in the groin, 
which occasionally came down in the daytime and 
disappeared at night, but he had never worn a truss. 
It descended the evening before, and caused consi- 
derable pain ; and although it went away during 
the night, the abdomen had continued painful 
during the day. Whilst straining himself at work 
in the evening it again made its appearance ; and as 
it occasioned considerable pain, he came to the hos- 
pital for relief The abdomen was tender on pres- 
sure and he complained of pain in it chiefly in the 
vicinity of the umbilicus. He did not feel sick, and 
his bowels had been open twice during the day. 
The pulse was full and hard. There was no tes- 
ticle on the right side of the scrotum, but the left 
was in its natural situation, and of proper size. I 
concluded that the tumour consisted of a retained 
testis which had been accidentally protruded at the 
external abdominal ring, and become inflamed from 
pressure, and that the inflammation had extended 
to the peritoneum, the latter membrane being, 
however, only slightly affected. I could not quite 
satisfy myself whether a portion of intestine had 
accompanied the testis, though this appeared very 
probable. I ordered the man to be bled to sxvj., 
fourteen leeches to be applied over the swelling, 
and a brisk cathartic to be given him. He con- 
tinued in suffering during the early part of the 
night, but having dropped asleep he found on 
awaking that the swelling had disappeared. The 
bowels were relieved in the course of the morning, 



IMPERFECT DESCENT OF THE TESTIS. 113 

but the groin and abdomen continued tender for 
two or three days. There was still a tendency to 
reprotrusion of the testis and intestine when the 
man coughed. A truss therefore was applied as 
soon as the pressure of it could be borne, which 
was six days after his admission, when he was dis- 
charged. 

Diagnosis in Cases of Imperfect Descent of the 
Testis. — A testis retained in the groin at the ex- 
ternal abdominal ring, or immediately below it, is 
liable to be mistaken for a bubonocele. It often 
occurs that it can be pushed back partially, or com- 
pletely, into the inguinal canal, but that it soon 
re-appears when the pressure is removed. There 
is then a swelling in the groin, admitting, like a 
hernia, of replacement, which might at first lead 
to the suspicion of rupture. The size, form, and 
solidity of the tumour, however, which, receives no 
impulse on coughing, the peculiar sensation pro- 
duced by pressure, and the absence of the testis 
from the scrotum, are sufficient to establish the true 
nature of the case, and to prevent it from being 
mistaken for either an intestinal or omental rup- 
ture. More difficulty is experienced in making the 
diagnosis, when an imperfect descent of the testis is 
combined, as it often is, with a congenital rupture ; 
and the case may be further complicated by the 
tunica vaginalis containing fluid, which can be 
passed up into the abdomen, but which returns 
when the pressure is removed. But, even in these 
cases, the empty state of the scrotum, and the pecu- 
liar pain excited by pressure on the gland, are usually 

15 



114 IMPERFECT DESCENT OF THE TESTIS. 

sufficient to prevent the surgeon from committing 
any serious error. When a testis detained in the 
groin becomes inflamed, the sickness and pain in 
the abdomen consequent upon the orchitis, tend 
very much to complicate the diagnosis, which is 
liable to be rendered still more perplexing by the 
effusion of blood or serum into the scrotum, con- 
cealing the absence of the testis, so that no slight 
skill and judgment are required to solve the diffi- 
culties of the case, as will appear from the following 
example."^ Mr. Pott was sent for in a great hurry 
to perform the operation of bubonocele on a young 
healthy seafaring man, who was suffering most 
acute pain in the groin and back. It appeared that, 
in the forenoon of the day before, he fell and struck 
his groin against a piece of timber, which gave him 
such exquisite pain that he fainted away, and his 
groin became immediately swollen to a very con- 
siderable degree. An apothecary bled him and 
poulticed the tumour, but he passed the night 
without sleep, and in great agony. The next morning 
he informed the apothecary, that he had long had 
a rupture on that side which had never perfectly 
returned. He was again bled, and some pains were 
taken to return the rupture. As the attempts pro- 
duced great increase of pain, they were desisted 
from, and two glysters and a purge were given, but 
without effect. The pain was exquisite, the patient 



* Delasiauve relates a case in which a testis retained at the groin, 
and inflamed, was mistaken for a strangulated hernia, and operated on. 
When the nature of the case was ascertained, the gland was extirpated. 
Revue Medicale, Mars, 1840. 



IMPERFECT DESCENT OF THE TESTIS. 115 

very sick, and the groin and scrotum were much 
swollen and very hard. The general appearance 
and figure of the tumour did not appear like that 
of a bubonocele. Instead of pointing obliquely from 
the ilium towards the pubes, it lay as it were across 
the groin ; the scrotum was full and large, but 
much harder than Mr. Pott had ever found a piece 
of intestine. The discoloration was not at all like 
the effect of mortification, but had all the appear- 
ance of ecchymosis. The man had not had a fair 
stool for three days ; he had been very sick, and had 
vomited ; his belly was tight, hard, and painful, 
and his pulse much too quick ; very little informa- 
tion was to be gained from examination of the 
tumour, for the pain was so exquisite that he could 
not bear the slightest touch. On enquiring further 
concerning the rupture, it was ascertained that he 
had worn a truss the first four years of his infancy, 
but that it never kept the gut totally or perfectly 
up ; and that, as he grew bigger and ran about, he 
was obliged to leave it off on account of the pain it 
gave him, that since, little or no alteration in the 
tumour had been observed, and that it had never 
given him any trouble or uneasiness, if he did not 
handle it or kept the waistband of his breeches and 
his watch from pressing it. All this being far 
from satisfactory, Mr. Pott determined before at- 
tempting any operation to try the effects of a brisk 
cathartic, which produced a plentiful discharge, and 
relieved all apprehensions of stricture. Under fo- 
mentations and poultices, &c., the tumour subsided, 
and in about seven or eight days the scrotum was 



116 LAIPERFECT DESCENT OF THE TESTIS. 

>o unloaded as to permit an accurate examination, 
by which it was ascertained that it contained no 
testicle. Upon mentioning this circumstance to 
the patient, he said, that he never had one on that 
side. This declaration was a solution of all diffi- 
culties, and of all the appearances. When all the 
effects of the blow were removed, there appeared in 
the groin a testicle of natural size and figure, which 
by being much bruised had caused all the mischief.^ 
It may seem unnecessary to direct the practitioner 
in all doubtful cases to make a careful examination 
of the scrotum. Yet it is surprising how apt the 
absence of the testis is to be overlooked, the defi- 
ciency not being ascertained until all attempts to 
reduce the supposed bubonocele have failed, and 
the patient himself being often unaware of any 
thing unusual in the state of the parts. The late 
Mr. Gilbert Burnett has recorded a case in which 
he honestly acknowledges to having committed this 
error.t Two cases in which this important point 
was overlooked have also come to my own know- 
ledge. 

Dupuytren has recorded an interesting case of 
hydro-sarcocele of the left testis coupled with 
hernia, consequent upon a late descent of the gland. 
The case was mistaken for simple hernia, and the 
patient had worn a truss. The diagnosis was ex- 
tremely difficult. The case was operated on ; and 
after opening the tunica vaginalis, and letting out 



* Lib. cit. p, 352, case 1. 

f Medical and Physical Journal, vol. Ixii. p. 508. 



IMPERFECT DESCENT OF THE TESTIS. 1 1 7 

eight or ten ounces of fluid, he extirpated the en- 
larged and indurated testis. The patient did well.^ 
Descent of the Testis into the Perineum. — Mr. 
Hunter first observed that the testis in changing 
its situation does not always preserve a proper 
course towards the scrotum, there being instances 
of its taking another direction, and descending into 
the perineum. How this is brought about he re- 
marks it is difficult to say ; it may possibly be oc- 
casioned by something unusual in the construction 
of the scrotum, or more probably, by a peculiarity 
in that of the perineum itself For it is not easy 
to imagine how the testicle could make its way to 
the parts about the perineum, if these were in a 
perfectly natural state. The first instance of the 
kind that occurred to him, was the child of a shop- 
keeper in Oxford Street, but what became of the 
patient afterwards he did not know. He was con- 
sulted in a similar case by Mr. Hunt, a surgeon in 
Oxfordshii^, who gave the following account of the 
patient : — " The boy is about twelve months old ; 
his right testicle is situated about an inch below the 
termination of the scrotum, and half an inch on the 
right side of the centre of the rapha perinei, where a 
kind of pouch is formed of the common integuments, 
without the least rugous or scrotal appearance 
on its surface. It is perfectly detached from the 
scrotum ; nor can the testis or spermatic process be 
at any time felt in any part of the scrotum, though 
I can readily make the testis pass from its situation 

* Lecons Orales, t. i. p. 74. edit Bruxelles. 



118 ATROPHY OF THE TESTIS. 

quite up into the groin ; but immediately upon re- 
moving my hand, the testis falls down into its 
pouch ; and I can trace the spermatic cord from the 
body of the testis up to the ring, running about a 
fourth of an inch on the right side of the scrotum. 
The scrotum on each side appears perfectly formed, 
and the left testis is in situ naturali." 

Mr. Adams has informed me that many years 
ago a little boy, one of whose testes had thus de- 
viated from its proper course, was brought to the 
London Hospital. The testis was lodged in the 
perineum at the root of the scrotum. The irre- 
gularity is exceedingly rare, and the above cases 
are all with which I am acquainted. 

This peculiar conformation is attended with great 
inconvenience and risk of injury to the testis, when 
the subject of it assumes the sitting posture, and 
rides on horseback. Mr. Hunter advised that the 
organ should be supported in a situation near the 
groin, by the application of a bandage that might 
hinder its descent into the perineum, by which the 
parts might be in time so consolidated as to retain 
it by the side of the scrotum. 



CHAPTER 11. 

ATROPHY OF THE TESTIS. 



The testes, like other organs formed for the exer- 
cise of temporary functions, do not arrive at a 
perfect state of developement until a certain period 



ARREST OF DEVELOPEMENT, ETC. 119 

of life, after which, their offices being no longer 
requisite, their activity ceases, and they become 
gradually and imperceptibly diminished. Thus 
we find that in early life they are small in propor- 
tion to the size of the body as compared with their 
condition at puberty, and that as old age advances, 
and the generative functions cease to be called into 
action, they undergo a diminution in size, their 
vessels grow less, the seminiferous tubes become 
small and contracted, and partially obliterated. In 
animals these changes are far more remarkable 
than in man ; for as the functions of the testes are 
exerted only at stated periods of the year, as the 
rutting or copulating season advances, these or- 
gans rapidly increase in bulk, and in its decline un- 
dergo a proportionate degree of wasting. In man, 
it sometimes happens that the testicles do not acquire 
their proper size at the usual period, their develope- 
ment being from some cause or other arrested ; and 
also, after the organs have arrived at their full and 
perfect growth, that occasionally one or both suffers 
a premature decay. Under the head, then, of 
Atrophy of the Testis, I shall consider, 1. Arrest of 
Developement ; and, 2. Wasting. 



SECTION I. 

ARREST OF THE DEVELOPEMENT OF THE TESTIS. 

If the congenital lesions to which the testis is 
liable had not been already treated of, the cases of 
absence of that organ described in the preceding 



120 ARREST OF THE DEVELOPEMENT 

chapter might be correctly referred to the present 
section, as the deficiency in these cases was no doubt 
the result of an arrest in the early developement of 
the organ. But the cases that I am now about to 
consider are those in which the subsequent evolution 
which the testes undergo at puberty is delayed 
beyond the usual period, or never takes place at all. 
Mr. Wilson relates a curious instance of his having 
been consulted by a gentleman twenty-six years of 
age on the propriety of entering the marriage state, 
whose penis and testicles very little exceeded in 
size those of a youth of eight years of age. He had 
never felt the desire for sexual intercourse until he 
became acquainted with his intended wife ; since 
that period he had experienced repeated erections, 
attended with nocturnal emissions. He married, 
became the father of a family ; and these parts, 
which at six and twenty years of age were so much 
smaller than usual, at twenty-eight had increased 
nearly to the usual size of those of an adult man.* 
Mr. Wilson mentions this singular case, as it will 
admit of question whether the parts alluded to 
became properly formed as to size, and possessed 
of the power of secretion, in consequence of being, 
although so late. in life, influenced by the passions 
excited by attachment to a particular female ; or 
whether the enlargement and proper action of the 
parts beginning, occasioned such passion first to 
exist. He thinks the probability in favour of the 
former supposition, in which opinion I certainly 
concur. 

* Lectures on the Urinary and Genital Organs, p. 424. 



OF THE TESTIS. 121 

Lallemand mentions having seen a man about 
thirty years of age, extremely fat, and without a 
beard or hair on the pubes, whose penis and tes- 
ticles appeared to belong to a child of from seven 
to eight years : he had never experienced erections 
or venereal desires.* — A young man was admitted 
into the physician wards of the London Hospital 
labouring under disease of the heart and dropsy, of 
which he died in about a month afterwards. On 
examination of the body, I found a considerable 
deposit of ossific matter in the mitral valve of the 
heart. Having been informed that there was some- 
thing uncommon in the state of the genital organs, 
I made a careful examination of the parts. The 
youth was seventeen years and nine months old ; 
the body measured five feet ^ve inches in height, 
and was plump and well formed. There was no 
appearance of beard or whiskers, or of hair on the 
pubes. The penis and testes were very small, not 
larger than they are usually found in boys of three 
or four years of age. The two testes were about 
equal in size, and one of them weighed only two 
scruples and one grain. Both organs were normal 
in structure, appearing like the glands in early life, 
when the tubular structure is very indistinctly 
developed. No spermatozoa could be detected. 
These were clearly instances of arrest of develop e- 
ment of the testes. As these organs are chiefly 
excited to action by an operation of the mind, it is 
easy to understand that they may sometimes remain 

* Des Pertes Serainales Involoritaires, t. ii. p. 380. 
16 



122 ARREST OF THE DEVELOPEMENT 

undeveloped owing to defective organization of the 
brain, an absence of sexual desires being invariably 
remarked in these cases. The cases which I shall 
hereafter adduce of wasting of the testes after inju- 
ries of the head, and the frequent absence of the 
venereal appetite in cretins and idiots, tend to 
strengthen this opinion. 

The following is a marked example of defective 
developement of the sexual organs, accompanied 
with imperfection of the brain : — An idiot, aged 
nineteen, subject to epileptic fits, died of typhus 
fever in the workhouse of the Hackney Union. As 
the circumstances were curious, Mr. Hovell of Clap- 
ton, kindly informed me of the case, and allowed 
me to make an examination of the body. The 
youth was of short stature, and the form of the body 
was not indicative of either sex, but the contour 
was rounded as in the female. There was no ap- 
pearance of hair about the face or pubes. The 
abdomen and other parts were covered with a thick 
layer of fat. The penis and scrotum were remarka- 
bly small, not larger than they are usually found in 
a child two or three years of age. Both testes were 
in the scrotum, but they were of very diminutive 
size ; the right weighed less than a drachm, and 
the left not more than twenty-three grains. The 
cremaster muscle was traced over the cord to the 
testis on both sides. The right gland had descended 
a very little way below the abdominal ring. The 
vessels of the cord were very small. The glan- 
dular structure and epididymis of both testicles 
were indistinct, and the vasa deferentia also ex- 



OF THE TESTIS. 123 

tremely small. Nothing remarkable was observed 
in the structure of the brain. The vesiculse semi- 
nales were unfortunately not examined. Mr. Hovell 
also showed me another inmate of the same work- 
house, a lad aged nineteen, and of weak mind, 
whose penis and testicles did not exceed in size 
those of a boy seven or eight years of age, and who 
had only a few scattered hairs on the pubes. 

In treating of the imperfect descent of the testis, 
I have remarked that this gland, when retained in 
the abdomen or inguinal canal, does not in general 
acquire its complete state of developement, and that, 
though frequently capable of secreting, it is com- 
monly small in size. I have also noticed, in cases 
of congenital inguinal hernia, that the testis, even 
in its natural situation, was not of its proper size 
at the period of puberty ; so that when the infirmity 
existed on one side only, the testis was not more 
than half or two thirds the size of the other gland. 
The arrest of growth in this latter case is attributa- 
ble to the combined eifects of the pressure of the 
protruded intestine on the vessels of the cord, and 
to the obstruction to the circulation caused by the 
application of trusses and bandages to the groin. 

SECTION II. 

WASTING OF THE TESTIS. 

In investigating the alterations in the nutritive 
condition of the testis, it is very desirable to hx, if 
possible, some standard by which they may be 



124 WASTING OF THE TESTIS. 

estimated. The size of the gland is neither uniform 
nor conveniently appreciated. Its weight, likewise, 
varies so much in different persons, and in the same 
individual at different periods, according as it has 
lately exercised its functions or remained inactive, 
and as it is full of semen or empty, that it is 
scarcely possible to determine on any accurate 
standard of this kind. According to Meckel, the 
weight of the testis including the epididymis is 
only four drachms, and according to Sir A. Cooper 
about an ounce. The former estimate is certainly 
too low, and the latter too high. I have weighed 
numerous testicles taken from persons in health, 
who have been cut off suddenly by accidental 
violence, and from those who have died of various 
diseases. In healthy adults, the weight of the 
gland was found to vary from four drachms to one 
ounce and one drachm. I have jfixed the mean 
weight at six drachms. In the most lingering 
cases of phthisis and in other emaciating diseases, 
the organ was never found to weigh less than three 
drachms. I should consider, therefore, the testis of 
an adult weiojhing less than three drachms as in a 
state of atrophy. 

A testis in an advanced state of wasting, not 
arising from disease of the gland, usually preserves 
its shape, but feels soft, having lost its elasticity 
and firmness. Its texture is pale and exhibits few 
blood-vessels, the tubuli and septa dividing the 
lobes are indistinct, and the former cannot be so 
readily drawn out into shreds as before. The epi- 
didymis does not usually waste so soon nor in the 



WASTING OF THE TESTIS. 



125 



same degree as the body of the testis. It some- 
times, however, loses its characteristic appearance, 
and I have even found it reduced to a few fibrous 
threads. The fluid pressed out of the wasted testis 
and epididymis is entirely destitute of spermatic 
granules and spermatozoa. In many instances, 
adipose tissue is deposited behind the tunica va- 
ginalis, and encroaches on the epididymis and pos- 
terior part of the testis. Mr. Gulliver has recently 
discovered fatty matter in the glandular substance 
of atrophied testes, and I have since had an oppor- 
tunity of confirming this interesting observation. 
— A man aged forty-six died in the London Hos- 
pital of dropsy, consequent on disease of the 
kidneys. The left testis 
was found wasted to one 
fifth its natural size. In 
addition to the presence 
of adipose tissue beneath 
the tunica vaginalis testis, 1 
recognised a quantity of yel- 
low matter irregularly dis- 
posed amongst the wasted 
tubuli. This matter, on 
examination in the micro- 
scope, proved to be fat glo- 
bules, and readily dissolved 
on the application of ether. 
The wasted testis with the 
fatty tumour above it is represented of its exact 
size in the accompanying engraving. The struc- 

G. 1. Epididymis. 3. Body of testis. 8. Fatty deposit. 



G 




126 WASTING OF THE Testis, 

tures composing the spermatic cord undergo a cor- 
responding diminution ; the cremaster muscle dis- 
appears, the nerves shrink, and the vessels are 
reduced in size and number. The vas deferens, 
though small, can generally be injected with mer- 
cury as far as the commencement of the epididy- 
mis. A testis atrophied from disease is not only of 
diminished size and weight, but is altered in shape, 
being uneven and irregular and sometimes of an 
elongated form. The surfaces of the tunica vagi- 
nalis are adherent, and its cavity is partly or en- 
tirely obliterated. There is no, or very little, trace 
of the proper glandular structure, the organ being 
converted into fibrous tissue of a firm texture. It 
loses its peculiar sensibility to pressure, but is some- 
times the seat of morbid sensibility. 

All those causes which produce decay in other 
parts likewise occasion wasting of the testis. Thus 
an impeded circulation, pressure, want of exercise, 
and loss of nervous influence, have been noticed as 
causes of atrophy of this gland. To these must 
be added certain causes which specially effect the 
testis. 

The following case related by Mr. Wardrop is a 
good example of atrophy from defective nutrition. 
A person, both of whose testicles were completely 
absorbed, nothing being felt in the scrotum but a 
loose vaginal coat, died of an aneurism of the aorta, 
formed at the origin of the spermatic arteries, both 
of which were obliterated.* Mr. Pott mentions an 

* Note to his edition of Baillie's works, vol. ii. p. 315. 



WASTIiNG OF THE TESTIS. 127 

instance of varicocele, in which the testis became 
atrophied from the injudicious application of a truss 
which interfered with the circulation, and occa- 
sioned great distension of the vessels.* In other 
cases of varicocele, in which no truss has been 
applied, the impeded circulation caused by the 
dilated veins has been sufficient to produce partial 
wasting of the testis, a circumstance which I have 
observed in many instances. A ligature on the 
spermatic artery is sufficient to cause a total decay 
of the testis,t which induced C. J. Maunoir to pro- 
pose its application for the removal of certain forms 
of sarcocele. 

The influence of pressure in causing partial 
atrophy of the testis is sometimes remarked in old 
cases of hydrocele and haematocele, in which the 
gland has been long subjected to compression from 
the retained fluid. In long standing cases of irre- 
ducible scrotal hernia, the gland is often found 
much wasted, owing, it is said, to the pressure of 
the intestines ; but I am inclined to attribute the 
atrophy in these cases to obstruction in the cir- 
culation through the vessels of the cord, caused 
both by the hernia and trusses improperly applied, 
as in many animals, and sometimes, also, in man, 
the testicles remain throughout life in the abdomen, 
where they are exposed to greater pressure from 
the intestines than in a rupture, without, how- 
ever, undergoing any diminution in size. Wasting 
of the testes was supposed to have been produced 

* Lib. cit. p. 471. 

t T have repeatedly proved this by experiments on dogs. 



128 WASTING OF THE TESTIS. 

by the compression occasioned by contraction of 
the cicatrix, after recovery from sloughing of the 
scrotum, in a case which occurred to M. Roux of 
Paris.=^ 

It has been said, that the testes waste in those 
persons who strictly adhere to their monastic vows, 
but I am not aware that there is sufficient au- 
thority for this remark. In persons who marry, 
after many years of abstinence from sexual inter- 
course, the testes undergo a certain degree of 
enlargement. These glands naturally remain some- 
what small when not called upon to exercise their 
functions ; but whilst they are in a condition for 
secretion, and can be further developed if excited, 
this state cannot properly be regarded as morbid 
atrophy. It is a great error, and one very hurtful 
to morality, to suppose that sexual connexion in 
early life is essential for the preservation of these 
organs. When the excretory duct of the testis is 
obliterated, so that there is no outlet for the fluid 
which is secreted, the organ becomes useless, and, 
it has been said decays. This, however, I have 
shown in a preceding chapter to be by no means 
a common result. The following is the most re- 
markable case I have met with of wasting of 
the testes, apparently from long^continued inac- 
tion : — A man fifty-two years of age, and much 
emaciated, was brought to the hospital in a half- 
insensible state, and sinking, in the severe winter 
of February, 1838. There w^as an extensive ulce- 

* .Tobert, Plaies d'Armes a Feu, p. 232. 



WASTING OF THE TESTIS. 129 

rated sore in the perineum, through which the 
urine dribbled away, no water passing by the penis. 
The man could give no account of himself; but his 
wife stated that he underwent an operation in the 
perineum, at the hospital, about twelve years ago ; 
that the water had passed from underneath ever 
since, and that he had long been out of health. 
He gradually sank, and died on the third day after 
his admission. On examination of the body both 
lungs were found hepatised, but the heart and 
abdominal viscera were sound. Both kidneys were 
diseased. The bladder was contracted and empty. 
The prostate was converted into a multilocular 
purulent cavity, the urethra covering it being rid- 
dled with the enlarged prostatic openings. Two 
ulcerated apertures, each a quarter of an inch in 
diameter, in the membranous part of the urethra, 
communicated with the sore in the perineum. The 
urethra was completely obliterated and impervious 
near the meatus, and strictured in other parts. 
Both testes were atrophied, being scarcely larger 
than hazel nuts, but the tubular structure was still 
apparent. There was a small hydrocele connected 
with the right testis. The severe disease of the 
urinary organs must have incapacitated this man 
for sexual connexion for a long period of years, and 
to this circumstance we must chiefly attribute the 
atrophy of the testes, since the organs were not 
otherwise diseased. 

In cases of enlargement of the prostate the ejac- 
uiatory canals sometimes become completely ob- 
structed. Under these circumstances, the semen 

17 



130 WASTIJNG OF THE TESTIS. 

secreted under excitement having no means of 
escape encumbers the testes for a time, but after- 
wards becomes absorbed, and it is said that atrophy 
of these glands sometimes follows ; but I cannot 
say that I have observed any instance of wasting of 
the organs from this cause. 

As examples of atrophy of the testes, from loss 
of nervous influence, may be adduced cases of para- 
plegia, in which these organs have been known to 
waste. Portar mentions the case of a robust man, 
aged thirty-five, who was attacked with painter's 
colic, attended with great debility of the lower ex- 
tremities. The testes diminished considerably ; 
and although he afterwards recovered from the 
paralysis of his limbs, these glands always remained 
wasted, and the man was incapable of the act of 
generation.* In the xxth volume of the Medical 
and Physical Journal there is an account of a case 
of recovery after fracture, with partial dislocation 
of the first and second lumbar vertebras, followed 
by paraplegia, in which three years afterwards the 
testicles were found entirely obliterated. It has 
been stated that the testes sometimes waste from 
injuries, or from compression of the spine at the 
origin of the spermatic nerves. In a man who had 
received a blow on the lumbar region, the testes 
gradually wasted away.t 

The most common cause of atrophy of the testis 
is the disturbance in its organization consequent 



*,Coursd'Anatomie Medicale, t. v. p. 434. 
{• Baillie's Works by Wardrop, vol. ii. p. 315. 



WASTING OF THE TESTIS. 131 

upon inflammation. As the inflammatory process 
ceases, the enlarged gland not only becomes re- 
duced to its original size, but it sometimes slowly, 
but steadily, diminishes, till at length very little 
vestige of it remains. Mr. Hunter has related three 
cases in which the testicle decayed in this way.* I 
have met with two instances of atrophy arising from 
this cause, and there are few surgeons of experience 
who have not witnessed cases of the kind. Wasting 
of the testicle has been observed to occur after an 
attack of orchitis in mumps, arising, as it is sup- 
posed, from the translation of inflammation from 
the parotid to the testis. Two cases of cynanche 
parotidea in the adult, in which atrophy took place 
in the gland chiefly aflected, are related by Dr. R. 
Hamilton.! I have witnessed one case, in which 
the patient attributed the loss of the gland to an 
attack of mumps in his infancy. Wasting is more 
liable to occur after inflammation of the body of 
the gland than after consecutive inflammation, in 
which the epididymis is the part chiefly aflected. 
One or both testes have been found to waste in 
persons who have indulged too much in sexual 
intercourse, or been addicted to onanism. Baron 
Larrey met with several cases of atrophy from ex- 
cessive venery, and abuse of strong drinks, amongst 
the soldiers of the Imperial Guard.J Sir B. Brodie 
has recorded two cases in which wasting was occa- 
sioned by over-excitement ; in one from onanism, 

* Treatise on the Venereal Disease. 

t Philos. Trans, Edinb. vol. ii. art. ix. p. 59. 

I Memoires de Chirurg-ie Militaires, vol. ii. p. 66. 



132 WASTING OF THE TESTIS, 

in the other from sexual intercourse.* I have also 
witnessed an instance of total atrophy of the left 
testis from excessive masturbation. In this case, 
and probably in the others just quoted, the wasting 
was preceded by an attack of inflammation, in- 
duced by inordinate excitement. 

It is a common belief that wasting of the testis 
is liable to be induced by the long-continued use 
of iodine. I have not met with any instance of it, 
and I know of no case in which the evidence is such 
as to render it at all clear that the decay of the 
gland was really occasioned by this remedy.! 
Iodine has been employed much more largely and 
generally since the time that this opinion was 
promulgated, so that if it exerts the influence on 
the testis which has been attributed to it, we might 
reasonably expect that the fact would have been 
satisfactorily ascertained by recent experience. 
Such however is not the case ; and I feel convinced 
that the effect of iodine in producing wasting of 
the testis, if it ever occurs, happens so rarely, that 
the liability to it cannot be regarded as any objec- 
tion to the free and long-continued use of this 
valuable remedy. 

Atrophy of the testes has been remarked in 
elephantiasis of the Greeks, a disease in which 
tubercles are developed in various parts of the skin. 

* London Medical and Physical Journal, vol. Ivi. p. 297. 

1 1 have heard of the case of a medical gentleman v^ho attributed 
loss of virile power and a diminution in the size of his testes to the 
continued use of iodine, but whether justly so I have no means of 
inquiring. 



WASTING OF THE TESTIS. 133 

Dr. Adams, in an account of the cases of that 
disease, observed in the Lazaretto, near Funchal, 
states that all those who were attacked with it 
before the age of puberty, never acquired the dis- 
tinguishing marks of that change in the consti- 
tution, and their testicles diminished in size, and 
that in those affected later in life the testicles 
became atrophied, and they lost the power of pro- 
creation.^ Mr. Peacock also noticed a wasting of 
the testicles in several cases of elephantiasis in the 
Leper Hospital of Colombo, in Ceylon.t A similar 
condition of these glands was remarked in a case of 
this disease, so rare in this country, narrated by Mr. 
Lawrence,:]: and also in another case at the London 
Hospital, which I recorded many years ago.§ 

Wasting of the testes is liable to occur after in- 
juries of the head. A few years ago a man who 
had met with an injury of this description, which 
had been followed by wasting of the testes, and the 
developement of tumours on each side of the chest, 
resembling mammae, presented himself at the dif- 
ferent hospitals in London. 1 saw him in March, 
1828, at the London Hospital, when he had the 
appearance of a man who had seen hard service. 
He stated that he was about fifty-nine years of age, 
a married man, and the father of several children. 
He had belonged to the legion in the Queen of 
Spain's service. About two years and a half pre- 

* On Morbid Poisons, p. 265. 

t Edinb. Medical and Surgical Journal, vol, liii. p. 139. 
I Medico-Chirurgical Transactions, vol. vi. p. 214. 
^ Vide Medical Gazette, vol. vii. p. 447. 



134 WASTING OF THE TESTIS. 

viously, in an attempt to jump over a trench in 
a retreat, he fell backwards, and injured the pos- 
terior part of his head. Whilst on the ground he 
received a bayonet wound on the left side, and a 
sabre cut on the forehead of the same side. He 
recovered from these injuries, and returned to 
England. Since the accident he had completely 
lost his virility. He had no desire for sexual con- 
nexion ; his penis had dwindled in size ; his right 
testis had gradually wasted, and was no larger than 
a horse-bean, and the left gland was also a good 
deal diminished in bulk. The skull at the occiput 
seemed somewhat flattened. Baron Larrey records 
the case of a man who was wounded in the back of 
the neck by a musket-ball, which traversed the 
extensor muscles of the head, and grazed the in- 
ferior occipital protuberance. He recovered from 
the injury, but the testes were reduced to a state 
of atrophy, and the penis shrunk and remained in- 
active. He also relates the case of a man of strong 
constitution and vigorous passions, who received a 
sabre wound which cut off all the convex project- 
ing part of the occipital bone, and exposed the dura 
mater, a portion of which was also removed. The 
patient lost the senses of sight and hearing on the 
right side, and experienced at the same time sharp 
pains in the course of the dorsal spine, and a sense 
of formication in the testicles, which organs sen- 
sibly diminished, and in fifteen days were reduced, 
especially the left, to the size of a bean. He soon 
afterwards lost all desire for, or remembrance of, 



WASTING 5F the TESTIS. 135 

sexual enjoyment.^ Hennen relates that a Por- 
tuguese soldier was struck by a shell, which shat- 
tered the superior part of the occipital bone, and 
drove in a portion of the left parietal. He re- 
covered, but completely lost the generative faculty.t 
Lallemand had for some time under his care at the 
hospital at Montpellier a man thirty years of age, 
who, in the expedition to Algiers, had received a 
large sabre wound at the nape of the neck. His 
testes were wasted, and venereal desire as well as 
erections had entirely ceased.J We cannot doubt 
that in these cases the loss of sexual desire and the 
wasting of the testes were the direct results of the 
injury to the brain, and they go far to prove the 
essential dependence of the functions of these glands 
upon the cerebral organ. The physiologist cannot 
fail to notice the rapidity with which the atrophy 
is stated in some of the cases to have succeeded the 
injury, and the extent to which it proceeded. The 
withering of the testicles was, indeed, so remarka- 
ble, that it can only be attributed to the sudden 
and complete extinction of the sexual instinct re- 
sident in the brain, and (if! may so express myself) 
to the immediate impression on the system of the 
future uselessness of these organs. In old age and 
in lingering diseases the decay of the testicles is 
extremely slow and gradual, and is never carried to 
the extent observed in cases of injury to the brain. 



* Memoires de Chirurgie Militaire, p. 262. 

t Military Surgery, 3d edit. p. 306. 

\ Pertes Seminales Involontaires, t. ii, p. 41. 



136 WASTING OF THE TESTIS. 

In fact, men have survived the power or desire of 
performing the sexual act many years without the 
testes being materially reduced in size. We have 
seen, too, that in animals the testes have been ren- 
dered useless by interrupting the vasa deferentia, 
without any such striking effect being produced on 
the glands as occurred in these cases of cerebral 
injury. 

Wasting of the testis sometimes takes place with- 
out any apparent cause. A well-grown boy between 
nine and ten years of age was observed to grow 
more delicate in his figure for some months. His 
mother discovered that his testicles had almost 
disappeared. On examination, it was difficult to 
find them, and when discovered, they did not seem 
larger than two full-grown peas. The mother 
asserted that he was born with them of the usual 
size, and that they continued to grow for some time 
afterwards."^ Baron Larrey relates, that in several 
soldiers of the army in Egypt, at the close of the 
campaign in 1799, the testicles almost entirely 
disappeared, for which he assigns no satisfactory 
cause.t 

An investigation of the causes of atrophy of the 
testis is sufficient to show that we have little power 
by any mode of treatment to promote the develope- 
ment or arrest the decay of this organ. They are 
commonly the result of actions beyond the surgeon's 
reach or control. In certain cases, as in atrophy 



* Lond. Medical and Physical Journal, vol. xxxvi. p. 174. 
t Lib. cit. vol. ii. p, 62. 



INJURIES OF THE TESTIS. 137 

from pressure, or an impeded circulation, we may, 
by judicious measures, assist in retarding the wast- 
ing process ; but a statement of the circumstances 
which conduce to this change is sufficient to indi- 
cate the means required to check its progress. 



CHAPTER III. 



INJURIES OF THE TESTIS. 



Although the testes, owing to their exposed situ- 
ation, are more liable to injury than any other 
glandular organ, they are preserved in a remark- 
able degree from the effects of external violence 
by their great mobility and capability of eluding 
pressure, and the nature and strength of their pro- 
tecting tunics. 



SECTION I. 

CONTUSIONS AND INCISED AND PUNCTURED WOUNDS. 

Contusions. — -The testis is in danger of being 
bruised in the exercise of riding on horseback, by 
the organ being struck against the pommel of the 
saddle, and many of the inflammatory affections of 
the gland are found to originate in this accident. 
It is sometimes forcibly compressed between the 

18 



138 CONTUSIONS, INCISED AND PUNCTURED WOUNDS. 

thighs, and is occasionally contused by a kick or 
blow. This injury usually occasions slight extra- 
vasation of blood within, or in the cellular tissue 
beneath the tunica vaginalis. The effusion some- 
times infiltrates the cord, and when the contusion 
has been particularly severe, it has been found to 
extend along the cord even to the kidney. A case 
of contusion of the testis, in which the extravasa- 
tion reached as high as the diaphragm, is related 
by Petit.^ The tunica albuginea is so dense and 
strong, that it is rarely ruptured, and it protects 
in a great degree the glandular structure from the 
effects of this injury. 

The consequences of a contusion of the testis are 
soon felt, and are often severe -^ the immediate 
effects of the injury resembling a good deal the 
symptoms produced by an injury of the viscera of 
the abdomen, owing to the connexion of its nerves 
with those of the organs in the abdominal cavity. 
The patient instantly experiences acute pain, which 
extends up to the loins, and forces him to bend his 
body forwards for relief, and he is seized with a 
sickening sensation, which is often accompanied 
with syncope, vomiting, and cold perspirations. 
But these symptoms are transient ; and in many 
instances, after recovery from the first effects of the 
injury, no further ill consequences are experienced ; 
the effused blood is removed and the testis, after 
remaining tender for a few days, is gradually re- 
stored to its former healthy state. The only treat- 

* Traite des Maladies Chirurgicales, t. ii. p. 477. 



CONTUSIONS, INCISED AND PUNCTURED WOUNDS. 139 

m«nt required in these slight cases is rest, support 
to the organ with a handkerchief or suspensory- 
bandage, and the application of a cooling lotion. 
In other instances, the contusion is followed by- 
severe inflammation, which seriously injures, and 
sometimes completely destroys, the organ. Fre- 
quently the injury lays the foundation of chronic 
disease, which is slowly developed shortly after the 
accident. These results will be considered in a 
future chapter of this work. So complete, how- 
ever, are the disorganizing effects of a severe con- 
tusion on the gland, that squeezing the testis was 
one of the modes adopted formerly in the Oriental 
courts for emasculating the attendants of the ha- 
rem f and I am informed that a similar plan of 
castrating bucks is sometimes resorted to by park- 
keepers in this country, and that, in the agricultural 
districts, calves and lambs are occasionally treated 
in the same way. Dupuytren states, too, that in 
Normandy horses are deprived of their testes by 
compression.t This, however, is not a very sure 
way of emasculating, as some of the tubuli are 
liable to escape injury, and the effects of the sub- 
sequent inflammation. 

Punctured and incised wounds of the testis are 
not in general followed by severe results. The 
organ has often been injured accidentally in ope- 
rations with a trocar or lancet, and the wound has 
afterwards readily healed. These injuries must be 

* A person rendered an eunuch in this way was termed S-ActoWc 
t Legons Orales, t. i. 



140 SELF-CASTRATION. 

treated according to the particular circumstances 
of the cases ; but the fact that they commonly do 
well should be remembered by the surgeon, that 
he may not too hastily despair of saving the gland 
in incised wounds even of a severe character. 



SECTION 11. 

SELF-CASTRATION. 

Persons ignorant of surgery have been known, 
like the pious Origen, to perform double castration 
on themselves, and have evinced considerable deter- 
mination and indifference to pain in accomplishing 
their purpose. It is natural to suppose that no one 
would attempt such an act, by which the perpe- 
trator deprives himself of a faculty whose possession 
is universally so highly prized, and whose loss so 
degrades the condition of man, except during a fit 
of temporary insanity. Yet I am strongly inclined 
to believe that self-castration is seldom undertaken 
without some strong motive intimately connected 
with the sexual functions, arising from a perverted 
use or guilty indulgence of them, and that some 
such cause may generally be ascertained by a little 
cautious inquiry. In some instances the attempt 
has been made by persons who have been unable to 
cure themselves of the odious vice of masturbation : 
such I suspect, was the motive that led to the act 
in the two following cases which have come under 
my notice ; in both, double castration was effectually 



SELF-CASTRATION. 141 

completed. — A lad aged sixteen was brought to the 
London Hospital in June, 1832, exhausted and faint 
with bleeding going on from two wounds in the 
front of the scrotum ; they were each about an inch 
in length, and situated at the sides of the raphe. 
Upon examination it was found that the scrotum 
did not contain the testes. The boy subsequently 
gave the following account of his case. He stated 
that for about a week he had suffered from low 
spirits. Early in the morning he suddenly resolved 
to do himself some injury : his first determination 
was to cut his throat, but he afterwards resolved 
to perform the following act of mutilation. Having 
left his home in the Whitechapel road for some 
fields in the neighbourhood, he first passed a piece 
of string tightly around the root of the scrotum ; 
he then made an incision to the extent of an inch 
on one side with a common penknife, and having 
squeezed the testicle through it divided the cord 
and removed the gland ; he then proceeded to ex- 
cise the other testicle in the same way. The loss 
of blood was considerable, and he endeavoured to 
restrain it by drawing the ligature tighter. He 
said he was not conscious of any pain in the opera- 
tion ; and though he could not assign any reason for 
selecting this mode of mutilation, he admitted that 
he had read in an encyclopaedia an account of cas- 
tration. The testes were found in the field where 
the act was committed. The cord was divided close 
to the testis on one side, and at about an inch from 
it on the other. Ligatures were placed upon the 
spermatic arteries, and in three weeks the wounds 



142 SELF-€ASTRATI0N. 

had completely healed. No symptoms of insanity 
were evinced whilst the boy remained in the hos- 
pital : he enjoyed good health and spirits, and he 
talked and joked concerning his situation, without 
appearing at all to feel his loss. — A man aged 
twenty-two was brought to the London Hospital in 
January, 1836, having cut out both his testicles. 
He had removed a small piece of the integuments 
and squeezed the testicles out through the opening, 
and excised them, having previously tied a piece of 
string tightly round the spermatic cords to restrain 
the haemorrhage. These had retracted into the in- 
guinal canals ; and Mr. Adams, who was called to 
the case, was compelled to introduce his fingers at 
the wound and draw down the cords, in order to 
secure the vessels separately. The man admitted 
that he had been in the habit of constantly practis- 
ing masturbation, and it was to rid himself of the 
perpetual desire to commit what he regarded as a 
great sin that he determined to remove the testi- 
cles. The wound healed without any unfavourable 
symptom . 

I am indebted to Mr. C. Hawkins for the follow- 
ing particulars of a case which occurred at St. 
George's Hospital at the time he officiated as house 
surgeon. A man about sixty years of age, much 
reduced in circumstances, and an inmate of a work- 
house in the neighbourhood of London, where he 
was employed as a schoolmaster, was about to be 
dismissed for having had connexion with an idiot 
girl in the same house, when (as he said), to rid 
himself of the offending members which had been 



SELF-CASTRATION, 143 

his ruin, he entirely removed with a razor both 
testicles and a considerable part of the scrotum. A 
medical man who was called to him immediately 
after the ablation secured the spermatic arteries, 
and then sent him to the hospital with his testicles 
in a paper parcel. Mr. Hawkins secured a small 
vessel which was still bleeding, and closed the 
wound in the scrotum with sutures. The part 
healed without a single bad symptom, and the 
patient left the hospital quite well in about five 
weeks, since which he had not been heard of. 

Mr. Liston relates that a boy in Edinburgh, 
wishing, as he said, to lead a " holy life," applied to 
be castrated. Mr. Liston recommended him to wait 
some time before he had the operation performed, 
observing that as he was still growing the testicles 
might be reproduced. After another interview, in 
which castration was again put off on the plea of 
his age, he called one evening at Mr. Liston's house, 
having attempted the operation with a penknife. 
One of the testicles was completely exposed, and 
merely hanging by the cord ; the boy, said, " he did 
not like to cut the string." The wound was 
dressed, and the boy handed over to the priest to 
be admonished, but he did not apply again.* 

Mr. Reid, surgeon, Markinch, states that he was 
called to a lad, a shoemaker, aged seventeen, who 
had attempted self-castration with a sharp-pointed 
knife. The right testicle was found hanging from 
a clean wound in the scrotum about If inch in 

* Lancet, vol. i. 1838-9, p. B8. 



144 SELF-CASTRATION. 

length. The tunica vaginalis was cut to the extent 
of half an inch, and the posterior part of the testicle 
was slightly lacerated. The testicle was returned 
into the scrotum, and the wound dressed ; the part 
was completely healed in about three weeks. He 
said that his reason for committing the deed was, 
that for some time past he had had such frequent 
and copious seminal emissions, that his master had 
quarrelled with him about soiling his sheets ; so to 
do away with this cause of disagreement he had 
committed the rash act. The great bleeding had 
prevented him from completing the operation.* 

Dupuytren mentions the case of an old man 
married to a young and trifling woman, of whose 
conduct he thought he had good reason to complain, 
who resolved to destroy himself, and completely ex- 
tirpated both his testicles. The cure was prompt, 
but the monomaniac shortly afterwards drowned 
himself.t 

It thus appears that these cases of self-mutilation 
usually do well, and that the state of mind under 
which the injury is inflicted does not operate pre- 
judicially to the patient's recovery. 

* Edinb. Medical and Surgical Journal, July 1837, p. 93. 
f Lecons Orales, t. ii. 



HYDKOCELE. 146 



CHAPTER IV 



HYDROCELE. 



The term hydrocele is usually applied to a chronic 
swelling produced by a collection of fluid in con- 
nexion with the testis or spermatic cord. But 
before I treat of this affection it is necessary to 
make a few observations on inflammation of the 
tunica vaginalis, or, as it is sometimes termed, acute 
hydrocele. 

The inflammatory changes of the tunica vaginalis 
resemble those of the other serous membranes. In- 
vesting, however, an organ not essential to life, this 
membrane when acutely inflamed very rarely comes 
under the notice of the pathologist. M. Roux in- 
jected, in the hospital of La Charite, the hydrocele 
of a middle-aged man : inflammation was developed, 
and appeared to be taking its ordinary course till 
the fourth day, when gangrenous erysipelas attacked 
the scrotum and surrounding parts, and caused the 
patient's death on the tenth day after the operation. 
On examining the tunica vaginalis he found that 
it contained a large quantity of whitish serum, in 
the midst of which floated flakes of albumen ; other 
flakes of the same kind formed a thick coating over 
the testis, and on the internal surface of the mem- 
branous pouch. The serous membrane beneath 

19 



146 



HYDROCELE. 



appeared slightly thickened, and of a deep red 
colour. The epididymis and the lower part of the 
cord were swollen, and constituted the more solid 
part of the tumour produced by the inflammation. 
The body of the testis was not increased in bulk, 
and it retained its natural consistence.* In the 
museum of the College of Sur- 
geons there is a beautifully in- 
jected preparation of hydrocele, 
showing the effects of inflamma- 
tion after the application of the 
caustic, which was presented to 
the college by Sir W. Blizard. It 
is represented in the annexed 
wood cut, which exhibits the sac 
with part of it cut away to show 
the swollen state of the epididy- 
mis, and the aperture made by 
the caustic (1) ; the tunica vagi- 
nalis is coated with flocculi of 
lymph. The sac of an inguinal 
hernia is seen above the hydro- 
cele. 

The sound state of the body of 
the testis, though surrounded by 
an inflamed serous tunic, whilst 
the epididymis partakes in the disease, has been 
accounted for by Gendrin. He says, when the 
subserous cellular tissue, which always participates 




* Journal General de Medecine, &c. torn. Iviii. p. 25 ; quoted from 
Gendrin, Histoire Anatomique des Inflammations, tom. i. p. 143. 



HYDROCELE. 147 

in the inflammation of a serous membrane, pene- 
trates into the interior of an organ, it becomes a 
ready means of communicating the inflammatory 
action ; but when the contiguous organ or subjacent 
part is of a diflerent structure from that of the cel- 
lular tissue, the extension of inflammation inwards 
is checked. Thus, in the case of the inflamed 
tunica vaginalis, the cellular tissue readily trans- 
mitted the morbid action to the epididymis, but the 
tunica albuginea arrested its progress to the body 
of the testis ; and this explains the fact that after 
inflammation of the tunica vaginalis excited by 
injection the body of the gland is rarely found to 
sufler. On the other hand, the epididymis is seldom 
attacked with inflammation without the disease 
being quickly propagated to the tunica vaginalis. 
In the examination of a testis affected with acute 
consecutive orchitis supervening upon chronic, I 
had an opportunity of observing the effects of in- 
flammation on the tunica vaginalis at a period 
somewhat later than in the case observed by Roux. 
The opposite surfaces of the membrane were con- 
nected throughout by loose cellular adhesions of a 
light reddish colour, and infiltrated with serum of 
a faint red hue : small quantities of the serum were 
isolated in diflerent parts in imperfectly formed 
cysts. The tunica vaginalis was changed in ap- 
pearance, being thickly covered with vessels carry- 
ing red blood, and in two or three places minute 
branches could be traced penetrating the false 
membranes. The adhesions were every where so 
loose as easily to admit of being broken down with 



148 HYDROCELE. 

the finger. On injecting with size coloured with 
vermilion a testis whose tunica vaginalis had been 
in a state of inflammation, both portions of the 
membrane presented a deep uniform scarlet hue. 
The lymph effused in inflammation becomes organ- 
ized in the same way as in other serous cavities, 
and very often forms adhesions between the op- 
posed serous surfaces. These adhesions after some 
time are rendered very firm and dense, and in old 
cases are often converted into a fibro-cartilaginous 
structure. The chief inconvenience which results 
from them arises from the greater exposure to 
injury of the testis, in consequence of its not being 
able to glide away from pressure so readily as 
before. 

In a testis which I had an opportunity of examin- 
ing some little while after an attack of acute in- 
flammation, I found the lymph on both surfaces 
of the tunica vaginalis presenting a honeycomb or 
lace-like appearance, similar to that often met with 
on the pericardium. If inflammation of the tunica 
vaginalis be very violent, it may end in the for- 
mation of pus ; suppuration, however, is a rare 
occurrence, except after the introduction of a seton 
or other foreign body for the cure of hydrocele, or 
after injections of too irritating a nature used for 
the same purpose. It was supposed at one time 
that the cure of hydrocele after injection was always 
accomplished by the complete adhesion of the two 
surfaces of the tunica vaginalis ; but more recent 
observations have proved that in many instances 
these adhesions are only partial, and that in some 



HYDROCELE. 149 

cases a cure is effected without any adhesion what- 
ever. In the latter case, it seems that the inflamma- 
tion produces an alteration in the secernent disposi- 
tion of the vessels, so that they cease to pour out 
serum in a preternatural quantity as before the ope- 
ration. We can thus understand how it happens 
that the cure of hydrocele by injection is not invaria- 
bly permanent ; for if the cavity remain either in part 
or wholly unobliterated, the vessels on the free sur- 
face of the membrane may again be called into 
action, in the same manner as before injection was 
performed. Inflammation of the tunica vaginalis 
is not only the most frequent disease of the testis, 
but it is also one of the most common affections to 
which the body is liable. In the different disorders 
of the gland this membrane usually becomes in- 
flamed at some period or other, and adhesions be- 
tween its opposed surfaces are scarcely less common 
than those of the pleura. In examining the testes 
of twenty-four adults, I found adhesions of greater 
or less extent in one or both glands in nine in- 
stances. The symptoms produced by active inflam- 
mation of the tunica vaginalis, and the treatment 
proper for its removal, are sufficiently comprehend- 
ed in the observations on acute secondary orchitis, 
of which disease it is a very frequent complication. 
The following table exhibits at one view the dif- 
ferent varieties and complications of hydrocele. 



150 HYDROCELE. 





S 


.2 




c 


KS 




bn 


a 




D 


ta 


w 


■Q 


E <> 


>% 


rt 


(T? 




O 


o 


'TD 


c 


a 


D_ 


D 


3 


H 


tH 


H 


<3) 


O 





J3 


-C 


-C 



G o .13 



cS = 






o rt 



a 



o 



G 



^ ffi 1 4 §■ 

^ — _ ^ a ^ Cl, 

O O O 02 K E-i M 



G 



H CQ 



^ r 

o 6 



■5 -^ "5 TD* -5 

*l i 'I S I '^* 

^ *^ ^ *^ r^ ^ g 

o c o c ?^ o 

O O O o ±1 

3 • ^* s -o ffi ^ s ^ s:- 

U fcC f>. ^g ^^3- ^U ^^ § ^' 



o 

a r-. 



SIMPLE HYDROCELE. OF THE TESTIS. 151 



SECTION L 

SIMPLE HYDROCELE OF THE TESTIS. 



The sac of the tunica vaginalis, like other serous 
cavities,»is liable to dropsical effusion. In its 
natural state this membrane is filled by a halitus 
which lubricates its opposed surfaces ; but when 
from any cause the action of its secernent vessels 
is increased, or the balance between the secreting 
and absorbent functions is disturbed, fluid accumu- 
lates in and distends the tunica vaginalis, giving 
rise to hydrocele. The fluid effused is usually 
transparent, and of an amber, pale yellow, citron, 
or straw colour, and resembles the serum of the 
blood ; but is occasionally thick, and almost as firm 
as gelatine. According to Dr. Marcet's analysis,* 
1000 grains of this fluid of the specific gravity 
1024*3 contained 80 grains of solid matter, of 
which 71*5 consisted of animal and 8-5 of saline 
ingredients : hence it appears that this fluid only 
diflers from the serum of the blood in possessing 
rather less animal matter. In an analysis of the 
fluid of hydrocele made by Dr. Bostock,t 100*00 
parts of the specific gravity 1024 were found to 
contain 

Water 91-25 

Albumen - - - - 6-85 

Uncoagulable matter - - - M 

Salts - - - - - -8 



10000 

* Medico Chirurg. Trans, vol. ii. p. 372. t Ibid. vol. iv. p. 72. 



152 SIMPLE HYDROCELE OF THE TESTIS. 

A quantity of flaky matter or flocculent albumen 
is sometimes found floating in the fluid ; and it 
frequently contains, especially in old people, choles- 
terine in the form of a multitude of minute shining 
particles. Messrs. Brett and Bird^ found 500 parts 
of the fluid of a hydrocele, which was of a dark 
grumous appearance, and contained a number of 
brilliant crystalline lamellse floating through it, to 
consist of 

Water ... - 441-50 

Albumen and colouring matter of the 

blood .... 51-07 

Cholesterine . - - - 5*40 

Animal matter and salts soluble in 

alcohol - - - - -90 

Animal matter soluble in water - -76 

Salts - - » « - -37 



500-00 



The quantity of cholesterine contained in nine- 
teen ounces of dark fluid full of these shining par- 
ticles, which I removed from an old hydrocele, 
amounted to only nine grains. In the examination 
of a testis taken from the body of a man of colour, 
who died at an advanced age from the eflTects of 
an enlarged prostate, I found the tunica vaginalis 
and its investing tissues very thick and firm, and 
the seat of cartilaginous and osseous deposits ; it 
contained about three drachms of a thick brownish 
substance, which, when dried, was found to be 
almost entirely composed of crystals of cholesterine. 

* Lond. Med. Gazette, vol. xii. p. 764. 



SIMPLE HYDROCELE OF THE TESTIS. 153 

This was no doubt a very old case of hydrocele, in 
which the more fluid parts having beea absorbed 
the cholesterine was left behind within the indu- 
rated sac. 

The quantity of serum which is sulFered to accu- 
mulate varies considerably. In this country it 
seldom exceeds twenty ounces, though it has been 
known to amount to several pints. The largest 
quantity which I have met with is forty-eight ounces. 
Mr. Cline is said to have removed from Gibbon the 
historian as much as six quarts."^ From a table of 
1000 cases of hydrocele which occurred at the 
native hospital of Calcutta, constructed by Dr. 
Dujat, it appears that the quantity of serum evacu- 
ated varied from less than ten to upwards of one 
hundred ounces. Of 370 cases of double hydrocele, 
the fluid was more abundant on the right side in 
109, and on the left side in 128. Of the 630 cases 
of single hydrocele, in rather more than a third of 
the number the quantity of fluid was under ten 
ounces ; in two sevenths it was from ten to nine- 
teen ounces ; in nearly a third from twenty to forty- 
nine ; and in eighteen cases the quantity of serum 
was from 50 to 120 ounces.t 

In simple hydrocele the testis is usually found at 
the posterior part, and rather below the centre of 
the sac ; its situation, however, is subject to vari- 
ations. Before the occurrence of hydrocele the 
tunica vaginalis may have been inflamed, and con- 
trjicted adhesions, so that the testis may be con- 

* Sir A. Cooper's Lectures, by Tyrrel, vol. ii. p. 92. 
t Gazette Medicale de Paris, 1838, p. 562. 

20 



154 SIMPLE HYDROCELE OF THE TESTIS. 

nected to the membrane in front ; in which case the 
serum accumulates on each side of, or above and 
below, the organ. Sometimes there are several 
adhesions, producing a sacculated arrangement, and 
forming what is termed a multilocular hydrocele. 
Occasionally the cysts thus formed have no com- 
munication with each other. In two instances 1 
have seen a membranous partition in the sac of a 
hydrocele, separating it into two distinct cavities, 
formed by a layer of false membrane. There is 
one kind of sac or pouch often met with in hydro- 
celes which does not appear to have been described. 
It is situated on the inner side of the testis ; but the 
opening into it is always found on the outer side, 
between the body of the gland and the middle of 
the epididymis. This sac, which varies very much 
in size, is formed by the disten- 
sion of the cul de sac which I 
have described as existing natu- 
rally at this part. Two examples 
of this kind of pouch in the Hun- 
terian Collection were shown 
me by Mr. Paget. One of them 
is represented in the accompa- 
nying figure. In large hydro- 
celes the epididymis is usually 
elongated and displaced ; and 
instead of a pouch being formed, 
the central part of the epididymis 
is drawn to some distance frgm 
the body of the testis. 

1. Aperture of the pouch, between the body of the testis and middle 
of the epididymis. 




SIMPLE HYDROCELE OF THE TESTIS. 



155 



In old hydroceles the sac is often a good deal 
thickened, the tissues enveloping it being condensed 
and converted into layers of dense facia, such as 
are commonly observed investing only hernial sacs. 
The fibres, also, of the cremaster muscle, having to 
support an increased weight, frequently become 
remarkably developed, and extend around the tu- 
mour. This, however, is not constantly the case ; 
for in some instances of hydrocele of large size I 
have found this muscle atrophied. The thickened 
sac after many years acquires a cartilaginous cha- 
racter, and it may even become more or less ossi- 
fied. In cases which have been frequently tapped, 
the sac is sometimes found closely adherent to the 
skin of the scrotum at the various points perforated 
by the trocar. In the collec- 
tion formed by the late Sir 
A. Cooper there is a prepara- 
tion (vide figure) showing a 
long narrow band of adhe- 
sion, passing from the ante- 
rior part of the testis across 
the dilated sac of the tunica 
vaginalis to the membrane 
in front, which is supposed 
to have resulted from a 
wound of the testis in the 
operation of tapping. Scar- 
pa was the first to notice 
that in all large hydroceles the spermatic vessels 
are separated and transposed, so that the artery 
with the vas deferens occupies one side of the 




156 SIMPLE HYDROCELE OF THE TESTIS. 



I 



watery tumour, and the veins the other side ; and 
sometimes both of these vessels, in the manner of a 
band, pass on both of the sides, or even upon the 
anterior surface of the vaginal coat at its lower 
part.^ 

In hydrocele the glandular structure of the testis 
is sound, and the organ capable of exercising its 
functions. The disease is strictly confined to the 
investing serous tunic. The testis is, however, 
frequently somewhat altered in shape, being flat- 
tened by the pressure of the confined fluid ; and in 
some instances it has been found partially atrophied 
from the same cause. 

Hydrocele is a very common disease in persons 
of all ranks in life, and in most climates, but more 
particularly in warm countries. It has been re- 
marked by surgeons in extensive practice in London, 
that a large number of the patients who apply to 
them for the relief of this affection have passed 
several years in the West Indies, or some other 
warm country. Dr. Farret has noticed the fre- 
quency of hydrocele in Barbadoes ; and, according 
to Mr. Martin, it is a very common disease amongst 
the natives of Lower Bengal.^ 

This disease occurs at all periods of life ; but 
commences in early infancy and at middle age, 
more frequently than at any other period. It is 
rather a common aflection within a few weeks after 



* Treatise on Hernia, tr. by Wishart, p. 74. 

I Medical Records and Researches, p. 182. 

X Trans, of Med. and Phys. Society of Calcutta, vol. vii. p. 204 



SIMPLE HYDROCELE OF THE TESTIS. 



157 



20 . 


. . 3 


30 . 


. . 13 


40 . 


. . 11 


60 . 


. . 16 


60 . 


. . 10 


70 . 


. . 6 


80 . 


. . 1* 



birth. In sixty cases of hydrocele, M. Velpeaa of 
Paris found, 

Between the ages of 15 and 

20 — 

30 — 

40 — 

50 — 

60 — 

70 — 

In a tablet of 1000 cases of hydrocele treated by 
iodine injection at the Native Hospital of Calcutta, 
it appears that none of the patients operated on 
were less than eighteen years of age ; about one 
twenty-fourth were not more than twenty years old; 
rather more than a sixteenth were from twenty-one 
to twenty-five years of age ; a little less than half 
from twenty-eight to thirty-five ; a little more than 
a quarter from thirty-six to forty-five ; and an 
eighteenth were upwards of forty-six years. 



* La Presse Medicale, Mai, 1837. 

f Table of 1000 Cases of Hydrocele treated by Iodine Injections 
at the Native Hospital of Calcutta, from Jan. 1, 1836, to Jan. 5, 
1838 ; constructed from the Registers by M. Dujat. 



Ages. 



From 18 to 20 years of age 
21 to 2.5 - - - - 
26 to 35 - - - - 
36 to 45 - - - - 
46 to 59 - - - - 
60 to 70 - - - - 



Cases of Single Hydrocele. 












Double. 


Total. 


Right. 


Left. 


Total. 


14 


11 


25 


16 


41 


51 


58 


109 


64 


173 


147 


147 


294 


179 


473 


72 


94 


167 


90 


257 


17 


6 


23 


20 


43 


4 


8 


12 


1 


13 


305 


325 


630 


370 


1000 



Gazette Medicale de Paris, torn. xvi. 1838, p. 561. 



158 SIMPLE HYDROCELE OF THE TESTIS. 

Hydrocele is generally single, but sometimes 
occurs on both sides. It is said more frequently to 
form on the left side than on the right. Of forty- 
three cases which occurred to M. Velpeau, in thirty 
the hydrocele was on the left side, and in nine on 
the right ; in four cases the side was not indicated. 
Of thirty-six cases observed by M. Gerdy,* in 
eighteen the disease occurred on the left side, in 
thirteen on the right, and in five on both sides. 
During the last few years I have carefully regis- 
tered the new cases of hydrocele coming under my 
notice in public and private practice. Of fifty-four 
cases of simple hydrocele, forty-nine were single, 
and ^ve double. Of the former, twenty-seven 
occurred on the right side, and twenty-two on the 
left. This result, which gives a slight predominance 
to the right side, does not therefore agree with the 
observations of Velpeau, Gerdy, and Dujat. In 
the table constructed by the latter, it will be seen 
that the disease prevailed rather more on the left 
side than on the right. Hydrocele in young infants 
is usually single, and, in my experience, more fre- 
quent on the right side. I have seen, however, a 
few cases of double hydrocele at this early period. 
A child six weeks old was brought to me on ac- 
count of a hydrocele the size of a hen's egg on the 
right side, and another little more than half that 
size on the left ; neither of them had any commu- 
nication with the cavity of the abdomen. 

Dropsy of the tunica vaginalis is usually regarded 

* Archives Generales de Medecine, 111 ser. torn. i. p. 60. 



SIMPLE HYDROCELE OF THE TESTIS. 159 

as purely a local affection, resulting from a dis- 
turbance of the nicely adjusted balance between 
the functions of secretion and absorption. The 
same general causes which tend to produce effusion 
in the other serous membranes we may conclude 
likewise operate in occasioning hydrocele. All 
circumstances which determine blood to the organ 
in excess, or impede its return to the heart, or 
which act in any way in disturbing the circulation 
through the gland, must be regarded as remote 
causes of the disease ; and, considering the exposed 
and depending situation of the testicle, the liability 
of its vessels to obstruction, and the irregular 
nature of its functions, there can be no difficulty in 
accounting for the frequency of this affection. I 
shall hereafter have occasion to mention that hy- 
drocele is often combined with inguinal hernia ; a 
disease obviously very favourable to the effusion of 
serum in the tunica vaginalis, owing to the pres- 
sure of the rupture on the veins of the spermatic 
cord, and which is often increased by the use of 
trusses and bandages. Hydrocele is occasionally 
developed after a violent strain or great fatigue, or 
after a slight blow on the gland which was con- 
sidered at the time to be too trivial to require 
attention. In many of these cases the effusion 
appears to originate in a low degree of inflammation 
of the tunica vaginalis. I have already stated that 
marks of previous inflammation are occasionally 
observed in the sacs of hydroceles. On examining 
the body of a man aged forty-nine who died of 
apoplexy, I found about two ounces of serum in the 



160 SIMPLE HYDROCELE OF THE TESTIS. 

vaginal sac of both testes, and also several old ad- 
hesions, and some spots of induration and thicken- 
ing of the testicular portion of the membrane. I 
have observed similar appearances in other cases of 
incipient hydrocele, as well as imperfect mnltilo- 
cular cavities and septa, and induration, and 
enlargement of the epididymis, clearly evincing 
that the part had been the seat of inflammation. 
In some few instances I have met with hydrocele 
under circumstances which have led me to suspect 
that the disease was connected with, or sympathetic 
of, a chronic affection of the urethra, as stricture 
and morbid irritation in the canal. Hydrocele 
occasionally results from the irritation produced 
by loose accidental bodies in the tunica vaginalis, 
which are more frequently present than is generally 
supposed. In disturbed states of the circulation 
from disease of the heart, the tunica vaginalis is 
not so frequently the seat of dropsical eflusion as 
the other serous membranes, with the exception of 
the arachnoid ; but this is partly owing to the pres- 
sure exerted around the testis by the accumulation 
of fluid in the cells of the scrotum, and the relief 
to the spermatic vessels afforded by the oedema. 
In cases, however, of general anasarca, I have very 
frequently found slight effusion into the vaginal 
sac combined with oedema of the scrotum. 

When the fluid collected in the tunica vaginalis 
is attended with disease and enlargement of the 
testis, the swelling is termed hydrosarcocele. This 
affection is generally consequent on chronic orchitis, 
but it is occasioned by other morbid changes. 



SIMPLE HYDROCELE OF THE TESTIS. 161 

malignant as well as innocent. In these cases the 
disease of the testis is the original complaint and 
source of the irritation that excites an undue secre- 
tion from the tunica vaginalis, acting much in the 
same way as a tumour in the abdomen does in oc- 
casioning increased secretion from the peritoneum; 
or as a tumour in the chest, or carcinomatous dis- 
ease of the lungs, in producing pleuritic effusion. 

Symptoms. — Simple hydrocele forms a swelling 
which is elastic and of an oval or pyriform shape, 
which fluctuates, and has a smooth and even sur- 
face, and which, commencing at the lower part of 
the scrotum, increases very gradually and without 
causing pain. At its back part the tumour feels 
firm and solid, and strong pressure there occasions 
the peculiar sensation experienced from compres- 
sion of the testis. The swelling is movable, but re- 
mains constant under pressure ; and in all positions 
of the body, and if not of large size, the spermatic 
cord can be felt above it. When examined by 
transmitted light, the tumour is found to be more 
or less transparent, except at the part where the 
testis is situated, the opacity there indicating the 
exact position of the gland. When the hydrocele 
is of considerable size, the integuments are ren- 
dered very tense, and the veins ramifying beneath 
the skin appear prominent and enlarged. The 
penis is also partly or entirely buried in the swell- 
ing, the skin which usually invests it being drawn 
forward into the scrotum, giving to the orifice of 
the prepuce somewhat the form of the umbilicus. 
The hydrocele, even when large, is seldom attended 

21 



162 SIMPLE HYDROCELE OF THE TESTIS. 

with pain ; though its bulk and weight produce a 
good deal of inconvenience, and, if not supported, 
the tumour produces a dragging effect on the sper- 
matic cord, which causes uneasiness in the loins. 
Its progress varies in different individuals, the hy- 
drocele in some instances being several months in 
attaining a size which in other cases it reaches in 
as many weeks. But its course is, in general, 
slow ; and twelve and even eighteen months may 
elapse before the swelling approaches the abdo- 
minal ring. Sometimes after arriving at a cer- 
tain magnitude it ceases to increase ; whilst in 
other cases its growth, though slow, is uninter- 
rupted. It rarely happens that a hydrocele attains 
any considerable magnitude because so much in- 
convenience is occasioned by the tumour when of 
large size that the patient obtains relief at an early 
period ; otherwise it might increase until it reached 
as low down as the knees, as has really happened 
in long-neglected cases. Mursinna mentions a 
case^ in which the tumour measured as much as 
twenty-seven inches in length and seventeen in 
width, which is, I believe, the largest hydrocele on 
record. 

The symptoms of hydrocele are liable to several 
modifications. It sometimes happens, especially in 
children, that the tunica vaginalis remains after 
birth unobliterated for some distance along the 
cord \ consequently, when fluid collects within it 
the swelling assumes a pyramidal and elongated 
form, and the relative situation of the testis is 

* Neue Medicinische-Chirurgische. 



SBTPLE HYDROCELE OF THE TESTIS. 163 

lower than in ordinary cases. Owing to a peculiar 
conformation of the tunica vaginalis, there is occa- 
sionally a slight contraction in the centre of the 
hydrocele, giving to the tumour the form of an 
hour-glass. When, too, the testis is adherent to 
the front of the sac, the serum accumulating on 
each side, or above and below, causes the swelling 
to assume an irregular shape. Fluctuation is some- 
times obscure, and in other instances is not distin- 
guishable at all, in consequence of the tension and 
thickness of the sac and membranes investing it. 
If the sac happens to be loose and not fully dis- 
tended, the*^^ testis may sometimes be felt. This is 
often the case in children. 

Mr. Pott remarks, " The transparency of the 
tumour is the most fallible and uncertain sign 
belonging to it : it is a circumstance which does 
not depend upon the quantity, colour, or consist- 
ence of the fluid constituting the disease, so much 
as on the uncertain thickness or thinness of the 
containing bag, and of the common membranes of 
the scrotum. If they are thin, the fluid limpid, 
and the accumulation made so quick as not to give 
the tunica vaginalis time to thicken much, the rays 
of light may sometimes be seen to pass through 
the tumour ; but this is accidental, and by no 
means to be depended upon. Whoever would be 
acquainted with this disorder must learn to dis- 
tinguish it by other, and those more certain, marks, 
or he will be apt to fall into very disgraceful as 
well as pernicious blunders."^ The value of trans- 

* Works, 4to. p. 394. 



164 SIMPLE HYDROCELE OF THE TESTIS. 

parency, as a sign of hydrocele, is rather under- 
rated in these remarks. In ordinary cases the 
surgeon should certainly be able to detect the dis- 
ease without its assistance ; and this is the more 
necessary, as its absence is no proof that the tumour 
is not a hydrocele. But it would be absurd to 
reject the aid of a symptom which, when present, 
constitutes one of the most certain signs of the 
disease, because of its inconstancy ; and, in the 
present day, there are few surgeons even of ex- 
perience who do not avail themselves, in cases of 
doubt, of this ready and simple mode of examina- 
tion. But, independently of the advantage to be 
derived from transparency as a means of diagnosis, 
we are enabled by this mode of examination to 
ascertain the exact position of the testis, which is 
always important before undertaking any operation. 
In cases of encysted hydrocele, or adhesion of the 
testis to the sac, the unusual situation of the gland 
may thus be detected, and risk of injury to it be 
avoided. The mode of making the examination 
generally adopted is to darken the room, and place 
a lighted candle so that the tumour may be inter- 
posed between the eye and the light. The testis is 
then readily recognised as an opaque object, and 
its situation exactly ascertained. In cases in which 
the parietes of the cyst are unusually thick, or the 
fluid is very dark-coloured, I have sometimes de- 
rived considerable assistance from using a wooden 
tube, about three quarters of an inch in diameter, 
open at both extremities. One end being placed 
against the swelling opposite the light, the surgeon, 



SIMPLE HYDROCELE OF THE TESTIS, 165 

on looking through the other, can observe the 
transparency with great advantage. If a more 
convenient tube be not at hand, a roll of writing 
paper will answer the purpose. The growth of a 
hydrocele is occasionally attended with a good 
deal of local uneasiness, which has been ascribed 
to pressure on a nerve, or to the presence of acci- 
dental cartilages in the cyst. I have generally found, 
when pain exists, that the dropsical collection has 
originated in and been kept up by some disease of 
the testis. A hydrocele sometimes varies in size, 
being larger and more tense in the after part of 
the day than when the patient first rises in the 
morning. I have not exactly observed this change ; 
but it has been so often mentioned to me by per- 
sons affected with hydrocele, that I entertain no 
doubt of the fact ; and since the extent of surface 
afforded by the dilated tunica vaginalis is large, 
and the condition of the parts during day and night 
very different, such variations in size consequent 
upon alterations in the functions of secretion and 
absorption do not appear at all unlikely to occur. 
I have been informed of a case in which the change 
was so remarkable that the scrotum, which was 
full and tense when the patient retired to rest, 
became contracted and corrugated by the time he 
rose in the morning. 

Diagnosis. — A hydrocele is usually distinguished 
without difficulty. The surgeon may conclude that 
a scrotal swelling is a hydrocele, if the tumour 
be tense, transparent, and fluctuating ; if it has a 
smooth and uniform surface ; and if the testis can- 



166 SIMPLE HYDROCELE OF THE TESTIS. 

not be felt, and its position can only be ascertained 
by the greater solidity of the swelling, and the 
uneasiness experienced on pressure at one par- 
ticular part, which is generally behind ; and if the 
spermatic cord can be distinctly felt of its natural 
size, and in a healthy state. The affections most 
likely to be confounded with hydrocele are scrotal 
hernia and malignant disease of the testis. A 
hydrocele differs from a scrotal hernia in the fol- 
lowing circumstances : — The swelling commences 
at the lower part of the scrotum ; whereas in hernia 
it begins at the ring, and gradually descends. The 
spermatic cord can be clearly felt above the tumour ; 
but in hernia it can only be traced indistinctly 
along the back part of the swelling, and some- 
times cannot be distinguished at all. The testis 
cannot be felt ; but in hernia, unless congenital, 
the gland can be readily perceived at the bottom 
of the swelling : and, further, there is no impulse 
communicated on coughing, and the tumour is not 
subject to variations in size, as in rupture. The 
diagnosis is made with less facility when the hydro- 
cele extends upwards along the cord nearly to or 
even into the ring, as in this case the cord cannot 
be felt ; and the shape of the tumour nearly re- 
sembles that of a scrotal hernia, and there may 
even be a slight impulse transmitted to it on 
coughing ; but attention to the other distinguishing 
marks which have been pointed out will always be 
sufficient to enable the surgeon to make an accu- 
rate diagnosis. 

To distinguish simple hydrocele from malignant 



SIMPLE HYDROCELE OF THE TESTIS. 167 

disease of the testis is not difficult, unless the 
parietes of the sac containing fluid be much thick- 
ened. But when the cyst is so thick and dense as 
not to admit the passage of rays of light, a careful 
examination is necessary to enable the surgeon to 
form a correct opinion. Like hydrocele, the dis- 
eased testis may present a tumour of an oval form, 
which has commenced at the lower part of the 
scrotum, and has formed gradually and without 
causing pain. It may also fluctuate indistinctly, 
and remain of uniform size under pressure, and in 
all positions ; and the spermatic cord may be felt 
above it in its natural state. In lightly balancing, 
however, the tumour in the hand, the diseased 
testis feels heavier than a hydrocele ; and its ex- 
ternal surface is seldom so even and uniform as, 
nor does it often assume the pyramidal form of, a 
hydrocele. On pressing the part occupied by the 
testis, if the tumour be a hydrocele the usual pain 
is experienced ; whereas if it be a malignant swell- 
ing of a large size, the disorganization is attended 
with loss of the natural sensibility of the gland. 
If the slightest transparency can be detected on 
inspecting the swelling through a tube in the man- 
ner explained (and I have not met with many cases 
of hydrocele in which transparency could not be 
perceived when the tumour was examined in this 
way), all doubt becomes removed. But in an ob- 
scure case the surgeon might introduce a grooved 
needle or trocar into the swelling, when, if the case 
be hydrocele, the escape of fluid would at once 
manifest the nature of the disease. I once met 



168 SIMPLE HYDROCELE OF THE TESTIS. 

with an indolent tumour of small size in the scro- 
tum of an old man, which was so irregular and 
uneven, felt so solid, and weighed so heavy, that 
it was impossible to determine exactly whether the 
swelling was occasioned by a morbid enlargement 
of the gland, a hoematocele, or a hydrocele with 
the sac unusually thickened and indurated. The 
age of the patient was such as to put an operation 
out of the question. He subsequently died of dis- 
ease of the chest ; and, on examination, I found the 
tumour to consist of a hydrocele, the sac of which 
wascartilaojinous and much thickened, and the con- 
tents a soft oleaginous kind of substance, consisting 
chiefly of cholesterine. The nature of such a swell- 
ing could only have been clearly ascertained by a 
puncture. The difficulty of the diagnosis, in cases 
of cartilaginous thickening of the tunica vaginalis, 
has been attested by Dupuytren. In a case of en- 
largement and induration of the left testicle, at- 
tended with lancinating pains in the groin and 
loins, and much emaciation, symptoms expressive 
of schirrous disease, and unaccompanied with any 
sign indicative of hydrocele, or scrofulous or vene- 
real disease, this distinguished surgeon, to avoid 
all chance of error, made an exploratory puncture. 
The result showed the prudence of this precaution ; 
for, instead of schirrus, the case was found to be a 
hydrocele, with cartilaginous thickening of the 
tunica vaginalis.* 

Treatment. — Though hydrocele is a disease free 

* Lecons Orales, torn. i. p. 49, edit. Brux. 



SIMPLE HYDROCELE OF THE TESTIS. 169 

from danger, it causes serious inconvenience and 
discomfort. When of large size, its weight is such 
that it has a dragging effect on the spermatic cord, 
and produces considerable uneasiness. This may 
indeed be obviated in a great measure by support- 
ing the tumour in a suspender ; and, as a general 
rule, the patient should always be directed to wear 
one. There are, however, other sources of annoy- 
ance. The tumour is constantly exposed to slight 
blows, and impedes the activity of the patient's 
movements. In warm weather troublesome exco- 
riations are often caused by the friction of the hydro- 
cele against the inner part of the thigh. The penis 
being partly buried in the swelling, micturition 
and the genital functions are more or less interfered 
with ; and as the tumour cannot be fully concealed 
by the dress, even motives of delicacy strongly 
incline the patient to desire its removal ; so that 
persons labouring under this complaint generally 
apply sooner or later to the surgeon for relief. 

A hydrocele may disappear without any treat- 
ment whatever. In infants this is a constant oc- 
currence, but in adults is extremely rare. Mr. 
Pott has recorded two instances of the spontaneous 
disappearance of a confirmed hydrocele in the adult. 
One is the case of a gentleman forty-five years of 
age, in which the dropsical collection dispersed 
during six weeks' confinement for a severe fit of 
gout. The other is the case of a middle-aged man, 
who whilst intoxicated fell down and struck his 
scrotum against a piece of scaffolding, which caused 
considerable ecchymosis. This disappeared in about 

22 



170 SIMPLE HYDROCELE OF THE TESTIS. 

a fortnight, when it was observed that the hydro- 
cele was much less in size than it was before the 
accident. In about three weeks more the whole of 
it had subsided, and it did not afterwards return."* 
Sir B. Brodie also mentions that he has met with 
two examples of the spontaneous cure of hydrocele. 
In one of them the removal of the disease appeared 
to have resulted from inflammation set up in the 
sact A hydrocele has also been known to disap- 
pear permanently after an attack of orchitis, conse- 
quent upon the extension of inflammation from the 
urethra. But these cases are exceptions to the 
general rule, and are not to be taken into account 
in determining upon the treatment to be adopted. 

Infants affected with hydrocele are frequently 
brought to the surgeon within the first or second 
month after birth, the tumour naturally enough 
exciting uneasiness in the mind of the mother. In 
these cases, all that is necessary in the way of treat- 
ment is a stimulating application, and support to 
the scrotum with a bandage. A lotion, composed 
of an ounce of the hydrochlorate of ammonia, four 
ounces of distilled vinegar, and six ounces of water, 
will generally cause the removal of the fluid. In 
many instances I have found it quickly disappear 
by occasionally painting the scrotum v/ith the tinc- 
ture of iodine. If the hydrocele does not disperse 
under this treatment in the course of two or three 
weeks, the tumour may be pricked with a cataract 



* Lib. cit. p. 413 and 414. 

f Lond. Med. Gazette, vol. xiii. p. 90. 



SIMPLE HYDROCELE OF THE TESTIS. 171 

needle, which will allow the greater part of the fluid 
to drain away. This is the only operation that I 
ever found necessary in treating hydrocele in in- 
fants ; and even acupuncture, which is a mild pro- 
ceeding, and devoid of danger, is seldom required. 
The cure of hydrocele has been attempted in the 
adult with external remedies. For this purpose 
highly stimulating lotions and liniments, frictions 
with iodine, tartar emetic, and mercurial ointments, 
and the repeated application of blisters to the scro- 
tum, have been employed. Dupuytren states that he 
has succeeded in removing hydrocele by blisters f 
whereas Sir A. Cooper remarks that he has tried 
repeated blistering without producing a cure.t I 
have applied blisters and the linimentum hydrargyri 
in several instances, and have also been unsuccess- 
ful.J In the two following cases I succeeded in re- 
moving hydrocele by external treatment. — A man 
aged forty-five, and in good health, came under my 
care at the London Hospital in 1838, on account of 
a chronic hydrocele on the right side which had 
appeared gradually without any obvious cause. 
It was first observed about three months before ; 
but as it had attained an inconvenient size, and was 
getting somewhat painful, he was induced to apply 
for relief The tumour being very tense, I at once 

* Lecons Orales, torn. iv. p. 239, edit. Brux. 

t Lib. cit. p. 178. 

I Blistering the scrotum is not always free from risk. M. Gerdy 
relates a case in which gangrene of the scrotum occurred after the 
application of a blister for the removal of hydrocele in a man sixty 
years of age. Archives Generales de Medecin, 111 ser. torn. i. 
p. 70. 



1 72 SIMPLE HYDROCELE OF THE TESTIS. 

introduced a trocar, and drew off twelve ounces of 
serum. The testis was then felt healthy in size and 
structure. I saw the man again in three days, at 
which time the swelling had increased to nearly 
half its former size, and was tender on pressure. 
Being desirous of attempting the cure of this com- 
plaint on antiphlogistic principles, and considering 
a case seen at so early a period favourable for the 
experiment, 1 directed four or five leeches to be 
applied to the scrotum twice weekly, the parts to 
be supported and kept cool with an evaporating 
lotion, and the bowels to be gently acted on with 
saline purgatives. This plan of treatment was pur- 
sued steadily for three weeks, during which period 
the swelling gradually decreased, and when all but 
entirely removed the man discontinued his visits. 
■ — A corpulent gentleman, fifty-one years of age, 
called to consult me on account of a hydrocele of 
the right testis, which he had observed for about 
six months. The fluid within the sac did not ap- 
pear to amount to more than three ounces, and it 
produced no inconvenience. I painted the scrotum 
with a strong solution of iodine, and directed the 
use of a suspender. This application was made 
twice, and in three weeks all the fluid had become 
absorbed. In a few weeks afterwards the fluid 
again began to collect, and the hydrocele was sub 
sequently cured by injection. 

I have employed local treatment in other cases 
of older standing, but without success. External 
applications have, indeed, so seldom proved of any 
avail, that after the age of puberty chronic hydro- 



■J 



SIMPLE HYDROCELE OF THE TESTIS. 173 

cele is considered incurable by such remedies ; and 
the time lost in the experiment, and the pain and 
annoyance they produce, are serious objections to 
any trial of them. 

The distended tunica vaginalis is liable to be 
ruptured by accidental violence, the fluid escaping 
into the surrounding cellular tissue, and producing 
oedema of the scrotum, instead of the defined 
tumour which previously existed. The oedema 
usually extends to the penis, and sometimes reaches 
the lower part of the abdomen, occasioning a dif- 
fused swelling, which might prove alarming to the 
inexperienced surgeon. The fluid, however, is not 
of an irritating quality, and is so rapidly absorbed 
that the accident is seldom attended with incon- 
venience. In these cases the hydrocele is removed 
for a time, and in many instances permanently ; 
but in general the fluid collects again. In a French 
periodical a case is mentioned by M. Serres of a 
Spaniard about forty years of age aflected with 
hydrocele, who was in the habit, when the tumour 
got sufficiently large to be troublesome, of mount- 
ing a horse, or taking some other violent exercise, 
until the swelling gave way. He stated that he 
had done this more than thirty times.'^ 

When a patient with hydrocele applies to a sur- 
geon, it is usual to resort at once to operative 
treatment, which is of two kinds — palliative and 
radical. 

* Lancette Francaise. 



174 SIMPLE HYDROCELE OF THE TESTIS. 

Palliative Treatment of Hydrocele by Operation. 

The palliative operation is exceedingly simple, 
of easy performance, and, if proper care be taken, 
free from danger ; but the relief it affords is only 
temporary. It consists in puncturing the tumour 
so as to allow of the escape of the fluid contained 
in the tunica vaginalis : the operation may be per- 
formed with a lancet or a trocar. The best place 
for making the puncture is about the centre of the 
anterior part of the tumour ; but the surgeon should 
first ascertain the situation of the testis, for when 
the position of the gland is altered by adhesions or 
other causes, it may be necessary to puncture the 
tumour at the side, or even behind. It is better, 
however, to avoid the posterior part if possible, as 
in this situation there is some risk of wounding the 
spermatic artery. Simple as the case may appear, 
the surgeon should omit none of the customary pre- 
cautions, for more mishaps have occurred in the 
treatment of hydrocele than in any other operation 
in surgery. 

The lancet was formerly used for this operation, 
but is not now employed ; for the whole of the fluid 
cannot well be evacuated through the opening thus 
made, without much squeezing and handling of the 
parts ; and there is also risk of the division of some 
small vessels, which by pouring blood into the tunica 
vaginalis may change the case to one of haematocele. 
The operation is therefore generally performed with 
a trocar, the canula of which is about two inches 
long and a line in diameter. In selecting an in- 



SIMPLE HYDROCELE OF THE TESTIS. 175 

strument the surgeon should see that the canula 
fits properly, and that its shoulder does not project 
too much ; or else, after the point of the trocar has 
penetrated the cyst, the canula may hitch outside 
it, and instead of entering the cavity push the 
tunica vaginalis before it. In such a case, if the 
accident be not perceived in time,, the testis or the 
back part of the cyst is very liable to be wounded. 
The trocar before being used should be thrust 
through a piece of wash-leather held tense, and 
unless it penetrates readily, the instrument is unfit 
for use. This advice may seem unimportant ; but 
it should be recollected that, in addition to the risk 
of converting the case into a haematocele, any 
bungling in an operation of so simple a nature as 
the tapping of a hydrocele may induce the patient 
to suspect a general want of skill. 

I generally prefer performing this operation with 
the patient standing before me ; but if he be timid, 
or liable to faint, he may be seated in a chair, or 
placed in the recumbent position. The surgeon, 
grasping the tumour behind with his left hand so 
as to put the integuments upon the stretch, and 
taking care not to wound any of the enlarged veins 
beneath the skin, should insert the trocar, previously 
well oiled, perpendicularly into the tumour with a 
brisk motion of the right hand ; and as soon as the 
sac is perforated, which is ascertained by the im- 
mediate cessation of all resistance, the instrument 
should be inclined upwards, in order to avoid injury 
to the testis, and the trocar withdrawn, whilst the 



176 SIMPLE HYDROCELE OF THE TESTIS. 

canula is simultaneously thrust forwards by the 
action of the thumb and forefinger : gentle pressure 
is then to be maintained until all the fluid is re- 
moved. By manipulating in this way all risk of 
the tunica vaginalis slipping off the tube, or of the 
testis and back of the sac being injured, is pre- 
vented. After the whole of the fluid has escaped 
the canula is to be withdrawn, and the edges of the 
wound slightly nipped together ; after which the 
only application necessary is a piece of adhesive 
plaister to cover the wound : the scrotum is to be 
suspended in a bag truss. The patient should be 
enjoined not to walk about much for the next 
twenty-four hours, and to abstain from active exer- 
cise for a day or two ; a precaution which is more 
especially necessary in individuals of an irritable 
or unhealthy constitution, or in advanced life. If 
this advice be neglected, acute inflammation of the 
tunica vaginalis is liable to succeed the operation. 
Some years ago I tapped the hydrocele of a healthy 
man fifty years of age, who, notwithstanding the 
caution I had given him, walked several miles the 
same afternoon ; the consequence was severe in- 
flammation of the sac, followed by sloughing of the 
scrotum. After much suffering he recovered at 
the expiration of eight weeks, with the disease per- 
manently cured. At a later period of life, if proper 
precautions be not taken, the palliative operation 
can scarcely be viewed as free from danger. Sir 
A. Cooper mentions two cases of persons in ad- 
vanced age, who having taken a long walk after 



SIMPLE HYDROCELE OF THE TESTIS. 177 

the operation, had inflammation and sloughing of 
the scrotum, which terminated fatally."^ 

The wound made by the trocar heals by the 
first intention. Friction of the scrotum against the 
dress sometimes causes slight inflammation, and 
even ulceration afterwards, so as to require the 
attention of the surgeon ; but this is seldom the 
case, and when it occurs is easily remedied by the 
ordinary means. Occasionally there is slight ex- 
travasation in the cellular tissue from a wound of 
some small vessel external to the sac, but very 
rarely to any extent so as to interfere with the 
healing of the wound. 

The operation is always admissible whenever the 
amount of fluid is suflicient to admit of the intro- 
duction of the trocar without risk of injury to the 
testis. It should be repeated as soon after the fluid 
has collected again as the tumour from its size or 
weight becomes troublesome. This varies greatly. 
I have had patients who for many years have been 
satisfied with the relief afforded by an annual 
operation ; and in one case the fluid did not collect 
in a sufficient quantity to need removal for four 
years, when I drew off no more than sixteen ounces. 
In other instances patients have returned to have 
the fluid evacuated again at the expiration of two 
or three months, and even of a much shorter period. 
Indeed, I have known the hydrocele to regain its 
former size in the course of two or three days. 
Many persons suffer pain and uneasiness from only 

* Lib. cit. p. 181. 
23 



178 SIMPLE HYDROCELE OF THE TESTIS. 

a small quantity of fluid, whilst others experience 
but little inconvenience until the hydrocele has 
attained a large size. In most cases the patient's 
feelings will be the best guide in indicating the 
necessity for a repetition of the operation. 

Many persons affected with hydrocele, which 
after being tapped appears very slowly, and without 
causing uneasiness, are so satisfied with the tem- 
porary benefit afforded by this slight and almost 
painless operation, that they desire no further 
relief than is derivable from its repeated perform- 
ance ; and as hydrocele is not a disease which if 
suffered to remain is commonly followed by im- 
portant consequences, such persons may be safely 
left .to consult their own inclinations. Some pa- 
tients are too timid to submit to any other kind of 
treatment, and others are unwilling to undergo for 
the permanent relief of so slight an inconvenience 
even the short confinement which might be required. 
Persons out of health, of an irritable constitution, 
or in advanced life, upon whom the radical opera- 
tion cannot be performed without risk, must like- 
wise be content with palliative treatment. 

The tunica vaginalis may be emptied by a punc- 
ture made with a needle ; when the fluid, instead 
of escaping externally, as in the former operation, 
gradually infiltrates the cellular tissue surrounding 
the sac, whence it is afterwards removed by absorp- 
tion. In this operation, which is termed acu- 
puncture, anarsarca of the scrotum is substituted 
for a common hydrocele. It was first suggested by 
Dr. Cumin of Glasgow, who at the conclusion of 



SIMPLE HYDROCELE OF THE TESTIS. 179 

some observations on the treatment of ganglion by 
a similar procedure published in 1825, remarks, 
that it has occurred to him that a cure of hydrocele 
might be accomplished by opening a communi- 
cation by means of the cataract needle, between 
the cavity of the tunica vaginalis and the cellular 
tissue of the scrotum.* He did not, however, 
submit this idea to the test of experiment. Several 
surgeons have subsequently claimed the merit of 
originating this operation as a palliative cure for 
hydrocele. Mr. Lewis, surgeon, of London, is 
entitled to the credit of having first recommended 
acupuncture to his professional brethren on the 
grounds of practical experience of its efficacy .;t 
though no doubt can be entertained that the plan 
had been previously resorted to by other surgeons, 
who had regarded it as either too simple or too 
unimportant to deserve a formal notice, or who 
perhaps did not sufficiently appreciate its value.J 
Mr. Lewis's practice is to puncture the tumour 
with a fine needle until a drop of fluid oozes out on 
withdrawing it, and in a few days the hydrocele 
will entirely disappear. The absence of danger, 
the slow re-accumulation of fluid, and the simpli- 
city of the operation, are the advantages which 
he considers to be obtained by this mode over 
the operation of removing the fluid at once. In 
performing acupuncture I employ the common 

"^ Edinb. Medical and Surgical Journal, vol. xxiv. p. 97. 
t Lancet, vol. ii. 1835-36, p. 206. 

I Vide note from Mr. Keate on the Treatment of Hydrocele, 
Medical Gazette, vol. xix. p. 789. 



!80 SIMPLE HYDROCELE OF THE TESTIS. 

cataract needle, which I usually introduce in two 
or three different places, rotating the instrument 
between the finger and thumb to render the open- 
ings in the sac sufficiently patent. A little serum 
generally oozes out from the puncture in the skin 
in drops, or issues in a stream for a few seconds, 
and then ceases. In the course of a few hours the 
scrotal swelling becomes a good deal changed, 
and instead of a tense, smooth, and defined tumour, 
presents an oedematous tumefaction, with a soft, 
doughy, and inelastic feel. In large hydroceles the 
oedema extends to the integuments of the penis. 
The swelling thus produced takes from three days 
to a week gradually to disappear, the scrotum in 
favourable cases being left in its natural condition, 
without any excess of fluid either in its loose cel- 
lular tissue or in the sac of the tunica vaginalis. 
The operation may be repeated again and again 
as the fluid returns, on each occasion before the 
tumour has acquired the same size as on the pre- 
ceding one, by which means the sac may some- 
times be gradually reduced to its natural size. 

Though the advocates of this operation have not 
claimed for it the merit of constantly affording 
radical relief, it has been observed that the re-accu- 
mulation follows less quickly than after the fluid 
has been evacuated at once by the trocar, and in 
many instances does not take place at all. This 
certainly accords with my own experience of this 
operation ; for, in six cases in which it was per- 
formed, the relief proved so far permanent that 
there was no return of the hydrocele after a period 



SIMPLE HYDROCELE OF THE TESTIS. 181 

of many months, when I lost sight of my patients. 
Similar success has attended this practice in the 
hands of several of my professional friends with 
whom I have conversed respecting it.^ The cure 
of the disease in these cases, as well as the slow 
re-accumulation in others, I conclude are owing to 
the support and compression afforded to the vaginal 
sac by the infiltration of the surrounding cellular 
tissue : they are not likely to arise from any inflam- 
matory change in the containing membrane. 

Acupuncture must be regarded, upon the whole, 
as a useful addition to our remedial measures for 
the treatment of hydrocele. It does not supersede 
the use of the trocar ; for the latter is scarcely 
more painful or less simple, and in careful hands is 
equally safe and free from hazard, whilst the im- 
mediate and certain relief which the trocar affords 
will always give it an advantage. Acupuncture, 
too, is ill adapted for cases of thickened sac ; and 
the chance of permanent benefit which it offers is 
too slight to add much to its value as a means of 
treatment. In very timid persons, in those of im- 
paired constitutions, and in children, and in some 
other forms of hydrocele not yet described, acupunc- 
ture may be resorted to with benefit, and even pre- 
ferred to the trocar. I am informed by Mr. Luke, 
that in the case of a gentleman who was about to 
proceed to a place in South America, where there 
would be no surgeon nearer his residence than 400 



* Two cases cured by acupuncture have been published by my 
friend Mr. Wahie in tlie Medical Gazette, vol. xxix, p. 949. 



182 SIMPLE HYDROCELE OF THE TESTIS. 

or 500 miles, he instructed his patient to perform 
this simple and harmless operation on himself. 

Radical Treatment of Hydrocele by Operation. 

The permanent and radical cure of hydrocele 
maybe effected by any of the following operations: 
— Incision of the sac ; excision or removal of the 
tunica vaginalis; caustic applied to the integu- 
ments ; a tent introduced into the tunica vaginalis ; 
a seton passed through the sac ; and injection of 
the sac with a stimulating fluid ; — all which plans 
appear to have been known to ancient practitioners."^ 

Incision. — The treatment by incision is the most 
ancient of all the methods which "have been em- 
ployed for the cure of hydrocele. In performing it 
the surgeon cuts gradually down to the cyst with 
a scalpel, and, making an opening into the upper 
part, introduces a director or the finger, and with 
a bistoury lays open the cyst as far as the bottom 
of the sac, so as completely to expose the testis. 
The wound is then dressed ; inflammation soon 
arises, and the tunica vaginalis becomes obliterated 
by adhesion ; or else suppuration ensues, and the 



* Those interested in the history of the methods of cure for hydro- 
cele may consult the writuigs of Sabatier (Medecine Operatoire), 
and the Treatise on Hydrocele by Sir James Earle. There are few 
diseases of the same importance which have been so much written on 
as this affection."" Besides being largely treated of in most works on 
surgery, hydrocele and the particular modes of curing it has formed 
the subject of distinct treatises by the following British writers : — 
Douglas, Else, Pott, Howard, B. Bell, Keate, Earle, Hoibrook, and 
Dease. Some of these works have run through several editions. 






SIMPLE HYDROCELE OF THE TESTIS. 183 

part heals by granulation. After the incision was 
completed, it was often the custom to stuff the 
tunica vaginalis with lint, or to apply some other 
coarse and irritating substance. This operation 
was consequently always succeeded by acute in- 
flammation of the sac, the constitutional effects of 
which frequently proved exceedingly severe. Many 
of the older surgeons, as Wiseman, Cheselden, 
Heister, and Sharp, have noticed the painful and 
even dangerous consequences which sometimes re- 
sulted ; and it is observed by Pott, that this "method 
can never be said to be totally and absolutely void 
of some danger."^ Mr. B. Bell of Edinburgh is 
the most recent authority in this country who has 
advocated this method of treating hydrocele, which 
he slightly improved upon by devising a less irri- 
tating mode of dressing.f 

My brother, Mr. H. Curling of Ramsgate, informs 
me that when in Paris he witnessed several cases 
of hydrocele cured by incision by Jobert ; but the 
treatment proved very severe, and confined the 
patients to bed for a long time. I have myself seen 
three cases of this disease attended with considera- 
ble thickening of the sac, which, after injections 
had failed, were successfully treated by incision ; 
and certainly the consequences were less severe 
than the representations of Sharp and Pott would 
lead us to expect : but in these cases the tunica 
vaginalis was evidently less disposed to inflamma- 
tion than usual. Incision is an operation rarely 

* Lib. cit. p. 441. f Treatise on Hydrocele. 



184 SIMPLE HYDROCELE OF THE TESTIS. 

resorted to in the present day ; and I quite concur 
in the general opinion, that the disease can be suc- 
cessfully treated by milder and safer means. When, 
however, a hydrocele is found to depend on the pre- 
sence of loose cartilages in the sac, a small incision 
for their removal is the only treatment that can be 
of service. The wound should afterwards be closed, 
and the admission of air as much as possible pre- 
vented. 

Excision consists in cutting down upon the 
tunica vaginalis and excising the greater part of 
it with a pair of scissors, the spermatic vessels and 
testis being left untouched. The wound, which is 
filled with lint and dressed, subsequently suppurates 
and heals by granulation. This operation is also 
one of considerable antiquity; but it long remained 
in disuse, until it was revived in England in the 
year 1755 by Mr. Douglas, who advised the removal 
of an oval portion of the scrotum, together with 
the cyst."^ About the same period Bertrandi and 
several surgeons of eminence in France adopted 
the operation. The consequences of excision were 
not less severe or dangerous than those of incision ; 
it was sometimes followed by gangrene of the scro- 
tum, and generally by much constitutional irritation 
and tedious suppuration. This operation is now 
nearly exploded. I have only once seen it practised, 
and that was in the case of a young man, in which 
the tunica vaginalis was remarkably thickened, after 
the operation of injection had failed. The symp- 

* Treatise on Hydrocele, p. 136. 



SIMPLE HYDROCELE OF THE TESTIS. 185 

tomatic fever which followed was mild, and the 
operation successful, the wound having healed com- 
pletely in three weeks. 

Mr. Kinder Wood, a provincial surgeon, has 
practised a modification of the operation of exci- 
sion,^ which is deserving of notice. He opened 
the tumour with a broad-shouldered lancet in the 
customary situation, the lancet in consequence of 
its figure making a larger incision into the external 
covering than into the tunica vaginalis. After the 
evacuation of the water through the opening, a 
small portion of the tunica vaginalis which pre- 
sented at the internal opening was slightly hooked 
with a small dissecting hook, and a portion so 
brought forward through the incision was cut off 
with a pair of fine scissors. The puncture was then 
closed, and supported with adhesive plaister. In 
three cases in which this operation was performed 
the wound afterwards healed by the first intention. 
In two of them there was no return of the hydro- 
cele when the part was examined several years after 
the operation ; and in the third he remarks, " A suf- 
ficient time has elapsed to decide upon its certainty." 
In these three cases the cure was completed with- 
out an abolition of the cavity. They were instances 
of a perfect cure of the disease, and not of one 
effected by the obliteration of a natural membranous 
sac. In a fourth case in which this operation was 
tried, it was succeeded by severe inflammation of 



* Observations on the Cure of Hydrocele without procuring- an 
Obliteration of the Sac : Medico-Chirurgical Trans, vol. ix. p. 38. 

24 



186 SIMPLE HYDROCELE OF THE TESTIS. 

the testis ; the patient, however was an unfavourable 
subject. It is not recommended in cases in which 
the sac is much thickened and indurated. 

This operation, being neither severe nor dan- 
gerous, must be viewed quite in a different light 
from the old method of excision. Mr. Wood's re- 
port, although his experience at the time it was 
published was very limited, is upon the whole fa- 
vourable ; but the advantages which he claims for 
this mode are not such as appear to me to entitle it 
to any preference over injection. Dr. Titley states 
that he tried it on six patients in the West Indies ; 
and although in some of them a very considerable 
portion of the tunica vaginalis was removed, yet it 
proved in every case unsuccessful.* We must con- 
clude, therefore, that the mild form of inflammation 
which Mr. Wood considers fit to supersede the mor- 
bid state of the vessels, the cause of the effusion, 
cannot be insured by his plan with that degree of 
security and certainty which alone would recom- 
mend its adoption in practice. 

Caustic. — In this method of treating hydrocele 
a caustic is applied to the scrotum, so as to destroy 
the integuments, and cause a slough extending to 
the tunica vaginalis. When the slough separates, 
the cavity of the tunica vaginalis becomes exposed, 
and the fluid within it escapes. This is followed 
by inflammation of the membrane, which after- 
wards contracts and closes by adhesion or granu- 
lation. The effects of the caustic are represented 

* Treatise on the Diseases of the Genitals of the Male, p. 340. 



SIMPLE HYDROCELE OF THE TESTIS. 187 

in the woodcut at page 146. In the preparation 
there is a small aperture in the tunica vaginalis 
about a quarter of an inch in diameter, produced by 
a slough, and the inflamed membrane is coated with 
delicate flocculi of lymph. The caustic, although 
a mode of treatment introduced at a later date than 
incision and excision, was practised by surgeons at 
a very early period. It has been particularly de- 
scribed and advocated by Mr. Else ; and Mr. Cline, 
a cautious man, and one of the best practical 
surgeons of his day, also appears to have formed a 
very favourable opinion of this remedy, which he 
considered the mildest mode of all others.^ 

The caustic is in some respects a better method 
of treatment than those previously in vogue, the 
inflammation which it excites being less active and 
dangerous ; but for many reasons it is an objec- 
tionable remedy. It occasions a needless destruc- 
tion of parts, and is liable to produce a tedious and 
unhealthy sore : its action cannot be regulated with 
such exactness as to insure an opening through the 
tunica vaginalis ; so that a fresh application of the 
caustic, or the introduction of a lancet or trocar, 
was often necessary to complete the process : its 
operation is slow, and the consequences are unne- 
cessarily severe and painful. The treatment by 
caustic has therefore been long superseded in this 
country by milder means. 

* Lectures on Surgery, from Notes by Dr. Wilkinson, Medical 
Gazette, vol. xxiii. p. 279. It must be observed that Mr. Cline's 
favourable opinion of the caustic was expressed previous to the ap- 
pearance of Sir J. Earle's work on the radical cure by injection. 



188 SIMPLE HYDROCELE OF THE TESTIS. 

Tent. — This method consists in keeping a wound 
made in the tunica vaginalis by a small incision, 
patent by introducing a tent of linen, lint, or 
sponge, or some more solid substance, as a canula, 
or piece of elastic gum catheter, so as to induce 
inflammation. In some instances, when the tent 
was not of an irritating nature and was soon 
removed, the inflammation excited terminated in 
the eifusion of lymph and the adhesion of the sides 
of the membrane. In other cases the result was 
less favourable, the inflammation ending in suppu- 
ration, and the obliteration of the cyst by granu- 
lation. The introduction of a tent into the tunica 
vaginalis is a very certain and effective mode of 
curing hydrocele, and at one period it was very 
commonly resorted to by practitioners. One of the 
most recent authorities by whom it is recommended 
is the late Baron Larrey, the distinguished French 
military surgeon. His plan was, after drawing off 
the fluid by means of a trocar, to pass a piece of 
gum elastic catheter through the canula into the 
interior of the tunica vaginalis, and to leave it there 
until sufficient inflammation to procure adhesion 
was excited. He speaks of this proceeding as being 
as mild as it is certain.^ Such has not proved to 
be the case in other hands ; and this, as well as the 
other forms of the tent, are in the present day 
rarely resorted to for the cure of hydrocele. 

Seton. — The use of the seton is a mode of treat- 
ment the invention of which is ascribed to the 

* Memoires de Chirurgie Militaire, torn. iii. p 407. 



SIMPLE HYDROCELE OF THE TESTIS. 189 

Arabians. It appears to have remained in disuse 
for many years before the time of Mr. Pott. This 
excellent surgeon having experienced the severe 
eifects of the methods of treatment already de- 
scribed, was induced to make trial of the seton, 
which he employed in numerous instances with 
success. His aim in the operation was to produce 
a cohesion without destroying the tunic, or causing 
it to slough. His improved mode of performing 
the operation has been particularly described by 
Sir James Earle,"^ who states that in less than 
twenty-four hours after the introduction of a seton 
consisting of coarse sewing silk, the scrotum and 
testicle began to inflame, and put on the appearance 
of a hernia humoralis, which was treated in the 
same manner as is usual in that complaint. When 
the swelling was diminished, and the parts were 
regaining their natural state, which happened about 
the tenth or twelfth day, the seton was gradually 
removed, a few only of the threads being withdrawn 
at a time. 

The setori is a better mode of treating hydrocele 
than the other plans which I have described ; but 
though a remedy less severe than these, it is not 
free from the same objection, of being very liable to 
produce more inflammation than is requisite for the 
cure of the complaint. It is still, however, em- 
ployed, and is found a very useful remedy in certain 
forms of the disease. Thus in cases of children af- 
fected with hydrocele, which does not disperse under 

* Treatise on the Hydrocele, p. 70. 



190 SIMPLE HYDROCELE OF THE TESTIS. 

the application of stimulating lotions, it is a common 
practice to pass an ordinary curved needle armed 
with a silk ligature through the skin and sac in front 
of the swelling, leaving a space of about an inch or 
an inch and a half between the ends of the ligature, 
which may be tied together to prevent its escaping. 
This soon excites inflammation in the sac, and 
causes the effusion of lymph ; and in three or four 
days or a week the silk thread is removed, and the 
hydrocele is subsequently cured by adhesion. I 
have also adopted this plan with success in encysted 
hydrocele of the cord, and in ordinary hydrocele of 
small size in the adult, and once in a larger one 
after the operation of injection had failed. Mr. 
Green of St. Thomas's Hospital has recently ad- 
vocated the plan by seton, in preference to that by 
injection.'^ His mode of performing the operation 
is nearly the same as that employed by Mr. Pott ; 
but there is this important difference, that the seton 
is retained a much shorter period, the average time 
being twenty-four hours, though it will vary in dif- 
ferent instances. In three of the eight cases treated 
on this plan which are reported, the reintroduction 
of the seton was necessary. In one case the cel- 
lular tissue of the scrotum suppurated, and in ano- 
ther an abscess formed in the vaginal membrane ; 
both required to be punctured. In two instances 
the seton was obliged to be removed in a few hours, 
on account of the excessive pain which it produced. 



* On the Treatment of Hydrocele by Setons, St. Thomas's Hospital 
Reports, No. 1, p. 59. 



SIMPLE HYDROCELE OF THE TESTIS. 191 

In the only three cases in which the seton operated 
mildly as well as successfully, one was cured in 
twenty-seven days, another in twenty-nine, and a 
third in about a fortnight. Mr. Green's account 
of these cases will, I think, induce few to prefer the 
seton to the treatment by injection in ordinary cases 
of simple hydrocele. 

Injection is a plan of treatment alluded to by 
Celsus, who advised the use of a solution of nitre. 
Lembert, in his (Euvres Chirurgicales (1667), re- 
commended the injection of sublimate dissolved in 
lime-water, and he has recorded several cases in 
which it was attended with success. The practice 
of injection, however, appears to have been for some 
time entirely laid aside, until it was revived about 
the middle of the last century by Mr. G. Munro of 
Scotland, who at first employed spirits of wine, but 
subsequently, in consequence of the pain which it 
excited, substituted wine.* This plan was soon 
afterwards adopted by several other surgeons in 
Edinburgh. Mr. S. Shiarp of London, about the 
same time, also made trial of an injection of spirits 
of wine in a case of hydrocele, which was cured 
after very severe inflammation and the formation of 
two abscesses. Douglas, Le Dran, and Pott, in their 
works, disapproved of injections, which towards the 
end of the last century fell again into disrepute, 
owing, it seems, to the too irritating nature of the 
fluids employed. Sir James Earle,t surgeon of 

* Munro on the Dropsy, 3d edit. p. 222. 

t The first edition of his Treatise on the Radical Cure of Hydrocele 
by Injection appeared in 1791. 



192 SIMPLE HYDROCELE OF THE TESTIS. 

St. Bartholomew's Hospital, is entitled to the credit 
of having introduced injections into general prac- 
tice by showing the advantages of a milder mode 
of proceeding ; and those who compare the effects 
of this operation, practised in the manner he re- 
commended, with the severe results of all those 
methods of treating hydrocele previously resorted 
to, will readily acknowledge the high value of this 
improvement. 

The apparatus requisite for the operation of in- 
jection is a trocar and canula, and an elastic caout- 
chouc bottle or brass syringe, capable of containing 
about four ounces of fluid, fitted with a movable 
brass tube furnished with a stop-cock. I generally 
perform the operation on the patient standing ; but 
it may be done equally well in the recumbent posi- 
tion, which is preferred by many surgeons. The 
hydrocele is to be punctured at the same place and 
in the same manner as in the palliative operation, 
but the canula is to be pushed in up to the hilt ; 
and after the serum is whglly evacuated, the tube 
of the elastic bottle is to be applied to the canula, 
and the stimulating liquid injected gradually until 
the tunica vaginalis is slightly distended. Before 
throwing in the fluid, the surgeon should endeavour 
to nip up the skin and tunica vaginalis around the 
canula with the thumb and forefinger. The quan- 
tity of liquid necessary to be injected is always 
much less than the amount of serum previously 
removed. The object of the operation is to apply 
a stimulating fluid to the entire surface of the sac ; 
and this may be accomplished with a small quantity. 



SIMPLE HYDROCELE OF THE TESTIS. 193 

as an ounce or an ounce and a half, by handling the 
scrotum, and in this way putting the fluid in motion 
after it is injected, so as to bring it in contact with 
every part of the serous membrane. When the 
tunica vaginalis is fully distended, part of the fluid 
is liable to be forced out, or to escape by the side 
of the canula into the scrotum, where it may cause 
inflammation and gangrene. If the fluid should not 
pass easily, the surgeon must immediately stop in- 
jecting ; for most probably the canula has slipped 
out of the sac, so that by persisting the surrounding 
cellular tissue would become infiltrated. Whilst 
the canula remains in its proper place there can be 
no impediment to the free passage of the fluid. After 
the injection has remained in for a few minutes, the 
stop-cock tube is to be withdrawn, and the fluid 
pressed out through the canula ; which being re- 
moved, the aperture in the scrotum may be closed 
with a piece of adhesive plaister. 

Different surgeons employ diflererit kinds of 
stimulating fluids for injection. Sir James Earle 
gave the preference to dilute Port wine, which is 
still commonly used in this country, in the propor- 
tion of one third, or one half, water. Solutions of 
alum, or of the sulphate of zinc (sj — sxvi), are also ' 
frequently employed. Other fluids have been used, 
as cold and warm water, and dilute spirits of wine ; 
and it is stated that the cure of hydrocele has even 
been effected by the injection of air and of chlorine 
gas.* The fluid which I generally employ is lime- 

* British and Foreign Medical Review, vol. xi. p. 267. 
25 



194 SIMPLE HYDROCELE OF THE TESTIS. 

water. Though a mild injection, it usually excites 
sufficient irritation to cure the disease ; and I have 
rarely had occasion to resort to fluids of a more 
stimulating nature. Injections, composed of the 
tincture of iodine diluted with water, have lately 
been employed by several English and Continental 
practitioners, who have reported most favourably 
of their success. The peculiar advantages which 
iodine injections have been represented to possess 
will shortly be considered. 

The fluid injected into the tunica vaginalis should 
be allowed to remain there from four to six minutes 
in the adult, and about two or three minutes in 
younger persons. In general the patient soon feels 
sick and faint, and experiences uneasiness in the 
course of the cord. The pain is sometimes so 
severe that the removal of the injection becomes 
necessary at the termination of a minute or two ; 
in other instances it may be retained for ten minutes, 
or even a longer period. The amount of inflam- 
mation which may be excited cannot always be 
estimated by the degree of pain caused by the injec- 
tion. There is great diflerence in the susceptibility 
of persons to stimuli ; and although inflammation 
is more readily excited in some than in others, its 
amount and intensity do not equally depend on the 
irritability of the individual. When, therefore, the 
suftering produced by the injection is considerable, 
the surgeon must not be too hasty in removing the 
fluid ; or he may find to his disappointment that, 
after the pain has subsided, sufficient action has not 
taken place for the cure of the complaint. Unless 



SIMPLE HYDROCELE OF THE TESTIS. 195 

the pain be very acute, the fluid should not be 
withdrawn before the usual time. 

The success of the operation depends a good 
deal on the after-treatment. If too much inflam- 
mation be apprehended, means must be taken to 
moderate it ; on the other hand, as a certain 
degree of inflammatory action is essential to the 
cure, if no pain or other symptoms arise the sur- 
geon must endeavour to excite it. Sir A. Cooper 
has laid down the following rules for the pa- 
tient ; — " If you be in much pain, lie down ; if 
you suffer but little, take exercise ; — if you be in 
much pain, eat very little, and drink only diluents ; 
if you suffer but little, take your dinner, and two 
or three glasses of wine. Come to me to-morrow."* 
He observes, " If on the morrow there be redness 
in the scrotum, considerable tenderness, and some 
swelling, the suspensory bandage is to be worn, 
the exercise to be moderated, and the diet is to be 
light ; but if there be little appearance of inflam- 
mation, it is right to grasp the scrotum in one hand, 
and gently tap it a few times with the other, to 
produce slight pain. Exercise and a generous diet 
are to be recommended until redness of the scrotum, 
swefling, and pain in the part be produced ; for the 
inflammatory swelling from the injection should be 
nearly as great as the enlargement which had been 
previously produced by the disease." My own ex- 
perience does not incline me to rely much on the 
prudence of the patient in regulating the measures 

* Lib. cit, p. 187. 



196 SIMPLE HYDROCELE OF THE TESTIS. 

to be pursued after the operation. If, as generally 
happens, symptoms of inflammation arise in the 
course of a few hours, I usually recommend the use 
of a suspender to keep the testis supported, and 
direct the patient to remain in the recumbent posi- 
tion until the acute symptoms begin to subside. 
If these precautions be neglected, there is risk of 
more inflammation being excited than is necessary. 
Should no symptoms of inflammatory action be 
evinced in the course of eight or twelve hours, the 
patient should be encouraged to move about ; and 
the testis may be handled, so as to occasion slight 
friction between the surfaces of the tunica vaginalis, 
in order to induce the requisite vascular excitement. 
If the swelling should become considerable, and the 
pain and constitutional disturbance be great, the 
activity of the inflammation must be moderated by 
leeches, saline purgatives, or tartar emetic, as in 
the treatment of acute orchitis. It sometimes 
happens that the inflammation goes on to suppur- 
ation, and occasions an abscess in the tunica vagi- 
nalis. I have never witnessed this ; but when it 
occurs an incision must be made through the inte- 
guments and sac, in order to paimit the free escape 
of the pus. Granulation will then ensue, and the 
cavity of the tunica vaginalis will becomie com- 
pletely and permanently ob iterated. Sir B, Brodie 
remarks, that he has never known suppuration to 
occur after the operation by injection, except in 
West Indians, and in them only in three out of a 
great number of cases. In these cases the injected 
fluid was not made stronger than usual, but was 



SIMPLE HYDROCELE OF THE TESTIS. 197 

even retained a shorter time — in one case only a 
single minute — and yet the inflammation was ex- 
cessive ; there was violent pain, and great consti- 
tutional disturbance.'^ It may be well to bear this 
observation in mind, so that in operating on per- 
sons from warm climates the injections may be of 
a mild character. 

I never inject a recent hydrocele, or one, how- 
ever small, the first time of tapping, as it occasion- 
ally happens that the fluid ceases to collect after its 
evacuation. When the fluid amounts to more than 
ten or twelve ounces the hydrocele is unfit for in- 
jection, because the extent of the serous surface in 
large hydroceles is liable to render the eflects of 
this treatment more severe than is desirable. In 
these cases it is better to draw oiF the fluid, and 
then wait until a smaller quantity is formed, when 
the operation may be undertaken with less risk. 
The surgeon should also be careful to ascertain that 
the dropsical eflusion is not dependent on existing 
disease of the testis. A man was admitted into the 
London Hospital with a double hydrocele on pur- 
pose to undergo the operation for the radical cure. 
He had been suffering for some time previously 
from disease of the larynx, which increased soon 
after his admission, and caused suflbcation and 
death. On examination of the testes, deposits of 
concrete pus were found in the substance of both 
the glands. In this case, had his state of health 
permitted of an operation, after removal of the fluid 

* liOndon Medical Gazette, vol. xiii. p. 93, 



198 SIMPLE HYDROCELE OF THE TESTIS. 

the diseased condition of the testes would probably 
have been detected, and injection, which could only 
have operated injuriously, would have been aban- 
doned. The fluid effused around the diseased tes- 
tis by producing pressure sometimes causes pain, 
and it may then be evacuated with benefit ; but I 
need scarcely add that to attempt the permanent 
removal of the hydrocele whilst the original dis- 
ease remains unsubdued, would be both fruitless 
and hurtful. The disease producing the enlarge- 
ment of the gland must be treated without refe- 
rence to the effusion, and it will commonly be 
found that as the affection of the testis subsides the 
hydrocele likewise disappears. Thus in several 
cases of hydrosarcocele consequent on an attack of 
orchitis, in which after drawing off the fluid the 
testis has been found tender as well as enlarged, I 
have succeeded by the exhibition of small doses of 
mercury, and by strapping, or by applying mercu- 
rial or iodine ointment to the part, in subduing the 
chronic inflammation of the gland and effecting the 
cure of the hydrocele. In some instances, however, 
in which inflammation of the testis or epididymis is 
the primary disease, the hydrocele and disposition 
to an increased secretion remain long after all 
morbid action has ceased. The case must then be 
regarded in the same light, and treated in the same 
way, as ordinary hydrocele ; but the surgeon will do 
right to recollect that where inflammation has once 
been excited, its return is usually induced more 
readily and by slighter stimulating causes than be- 
fore. An enlarged and indurated testis or epididy- 



SIMPLE HYDROCELE OF THE TESTIS, 199 

mis does not, then, constitute an absolute objection 
to the operation for the radical cure of hydrocele ; 
but the proceeding would not be advisable unless 
the original disease had been long in abeyance. 

In favourable cases the operation of injection is 
followed by only slight pain, tenderness, and swell- 
ing, and by scarcely any constitutional disturbance ; 
and when performed with care it is devoid of danger. 
The chief risk arises from the stimulating fluid 
being injected into the cellular membrane around 
the tunica vaginalis instead of into the sac, owing 
to the canula slipping out of the opening. This 
accident is commonly succeeded by diffuse inflam- 
mation of the cellular substance of the scrotum, 
which is very liable to produce suppuration and 
gangrene, and in persons advanced in life or of a 
debilitated constitution it has caused the loss of 
life. An unfortunate case of this kind must be 
treated upon the same principles as a case of ex- 
travasation of urine. Free incisions should be made 
into the scrotum at a depending part, in order to 
allow of the escape of the irritating fluid, and fo- 
mentations and cataplasms afterwards applied. If 
gangrene ensue, the patient's powers will probably 
require to be supported by wine, brandy, and bark 
or ammonia. This accident never ought to happen, 
for it may always be avoided by proper care and 
caution : even when it does occur, it is not invari- 
ably succeeded by serious consequences, and two 
cases have come to my knowledge in which dilute 
Port wine was injected into the scrotum without 
any ill effects resulting. Another accident liable 



200 SIMPLE HYDROCELE OF THE TESTIS. 

to attend this operation is an attack of tetanus. I 
am informed by my friend Mr. Edwin Quekett of 
Wellclose Square, that a patient upon whom he 
had performed the operation was afterwards seized 
with locked jaw, which proved fatal. It is stated 
that in a native of the South of Spain, whose hy- 
drocele had been injected by Sir A. Cooper, teta- 
nus supervened : the patient fortunately recovered.* 
Mr. Travers mentions that similar consequences 
have attended this operation in the West Indies.t 
An attack of tetanus is, however, so rare an occur- 
rence, many thousands having undergone injection 
without an attack, that so remote a liability cannot 
be regarded as constituting the slightest objection 
to the performance of the operation. 

In six or seven days after the operation the pain 
and swelling generally begin to subside, and in 
about three weeks the cure is usually accomplished, 
all the effused fluids having been removed. But 
sometimes, especially if the inflammation has been 
unusually severe, this process takes place more 
slowly, the cure not being completed for two or 
three months. I have already observed that though 
injection sometimes eflects a cure by producing 
complete adhesion of the surfaces of the tunica 
vaginalis, it more commonly happens that the 
adhesions are only partial, and that the effusion 
is often checked merely by an alteration in the 
secernent disposition of the vessels. When adhe- 

* Prov. Med. and Surg. Journal. 

t Inquiry into Constitutional Irritation, part ii. p. 293. 



SIMPLE HYDROCELE OF THE TESTIS. 201 

sion is complete the cure is permanent, and the 
patient free from all liability to a relapse ; but if 
the hydrocele is removed without perfect oblitera- 
tion of the cavity, the relief may be only temporary, 
and the same causes which originally gave rise to 
the hydrocele might, at a future period, occasion a 
return of it. Instances are known in which a hy- 
drocele, after having been removed by injection, 
has reappeared at the end of ten, and even twenty 
years. In cases in which the operation fails, the 
injection may be repeated with a more stimulating 
fluid. We sometimes find the tunica vaginalis in- 
disposed to contract adhesions, or to undergo any 
change in its actions, since highly stimulating in- 
jections repeatedly fail to prevent the return of the 
dropsy. In such cases the surgeon is compelled 
to resort to some of the other operations for the 
radical cure which are of greater severity than 
injections ; as the seton, or incision. 

In double hydrocele injection should not be per- 
formed on both sides at the same time ; for not only 
may the effects of a double operation prove very 
severe, the degree of inflammation and suffering 
produced being always uncertain ; but the injec- 
tion of one has been known to succeed in curing 
both, by the extension of the inflammatory action 
from one sac to the other, their external sur- 
faces being nearly in contact. A man fifty years 
of age entered Dupuytren's clinical ward at the 
Hotel Dieu with double hydrocele. That on the 
right side was large and of old standing ; the other 
was small and recent. Dupuytren punctured and 

26 



202 SIMPLE HYDROCELE OF THE TESTIS. 

injected the first with wine, which caused the usual 
reaction, and the disease was cured on both sides. 
He had observed the same phenomenon several 
times.^ I am inclined to think these patients were 
fortunate, and that few surgeons have met with 
similar success from a single operation. The second 
hydrocele may be injected as soon as the effects of 
the first operation have subsided, and its result has 
been ascertained. 

Iodine Injections. — These were first tried by Mr. 
Martin, a surgeon in India.t He used the tincture 
in the proportion of sij — 3vj of water ; injected only 
a small quantity ; and instead of afterwards with- 
drawing the fluid, allowed it to remain in the sac 
to be removed by absorption. In a recent report 
of cases of hydrocele thus treated at the Native Hos- 
pital of Calcutta,:]: it is stated that from the 9th of 
March, 1832, to 31st of December, 1839, 2393 cases 
were under treatment. Of these 

1265 were Hindus, 
1076 " Mahomedans, 

52 " Christians. 



2393 
And it appears that the failures were rather under 
one per cent. ; a result which must be regarded as 
remarkably successful. The success and safety of 
iodine injections must be in a great measure attri- 
buted to only a small quantity of fluid having been 

* Lancette Francaise, Fevrier, 1837. 

t Transactions of the Medical Society of Calcutta, vol. vii. 

X Lancet, April 30, 1842. 



SIMPLE HYDROCELE OF THE TESTIS. 203 

thrown into the sac, so that risk of cellular effusion 
was avoided, and to the retention of the fluid in- 
suring the excitement of sufficient inflammation to 
cure the disease. Iodine injections have since been 
tried in Europe, by Velpeau, Ricord, and others, at 
Paris ; byOppenheim at Hamburgh; and by several 
surgeons in this country. The success which at- 
tended the practice of the former, as appears from 
their reports,^ has not been greater than that com- 
monly obtained in England with other injections in 
the hands of judicious practitioners. Mr. Walne 
has published an account of the results of his prac- 
tice with iodine injections in this country ,t and has 
narrated four cases, selected from many others, in 
which they were successful. He reports very fa- 
vourably of the plan, which, he states, produces a 
mild degree of inflammation, but slight suffering, 
and an expeditious cure. He allowed, however, the 
injection afterwards to escape from the sac instead 
of retaining it, as practised by Mr. Martin. Mr. 
Bransby Cooper also states that he has employed 
iodine injections in hydrocele with marked success. 
He injected two drachms of the fluid of the same 
strength as that used by Mr. Martin, and also left 
it in the sac.J I have found injections of lime- 
water answer so well that I have had no induce- 
ment to make trial of new remedies, and cannot 
therefore speak from personal experience of the 

* Vide Dublin Journal of Medical Science, vol. xiv. p. 219. La 
Presse Medicale, Mai, 1837. 

t Medical Gazette, vol. xxix. p. 949. 
\ Prov. Med. and Surg-, .lournal. 



204 SIMPLE HYDROCELE OF THE TESTIS. 

efficacy of iodine. But I much question whether 
this injection possesses such superior advantages as 
have been represented by many who have employed 
it. I do not believe that it exerts any peculiar 
or specific influence on the serous sac ; like other 
injections it can only act as a stimulant exciting to 
inflammation,"^ and like them it is liable occasion- 
ally to fail, owing to difierences in the susceptibility 
of individuals. Indeed, several of my medical 
friends, including Mr. Busk, surgeon of the Dread- 
nought Hospital, who have tried iodine injections, 
have assured me that though usually successful, 
they did not answer better than port wine, and 
that in many cases their effects were equally 
severe. The evidence, however, in favour of this 
injection in hydrocele is so strong, that we cannot 
hesitate to admit that it is a valuable and efficacious 
mode of treatment, and perhaps as successful as 
any other injection which has been resorted to for 
the cure of the disease. YVe must too, in justice, 
allow that it is a remedy which has been skilfully 
and judiciously employed, and that the strength of 
the injection, as first used by Mr. Martin in India, 
is well adapted to excite the exact amount of in- 
flammation required. 

In employing this injection, Mr. Walne recom- 
mends that those parts of the instruments which 
are metallic should be protected against the action 

* In a case of hydrocele successfully treated with iodine injection, 
M. Velpeau had an opportunity some time afterwards of examining the 
parts ; he found cellular adhesions established through the whole of 
the tunica vaginalis. Archives Generales de Medecine, Janvier, 1837. 



SIMPLE HYDROCELE OF THE TESTIS. 205 

of the iodine by being carefully oiled beforehand, 
and freed from what may remain upon them by 
being dipped into a solution of potassa immediately 
after being used. If some care of this kind be not 
bestowed, they will quickly be corroded and in- 
jured, the affinity of iodine for metallic substances 
being very strong, and its effect destructive. 

[Electro-puncture has been recently proposed for 
the cure of hydrocele. It is performed by intro- 
ducing two acupuncture needles into the sac and 
connecting one to the positive and the other to the 
negative pole of a Daniel's constant battery. The 
action may be kept up from ten minutes to an 
hour. Dr. Ruschenberger of the U. S. Navy suc- 
ceeded in curing a case after both seton and* in- 
jection with iodine had failed, by a single intro- 
duction of the needles kept excited for half an 
hour. Dr. Washington of New York has at this 
time a case under treatment which promises to be 
entirely successful. — Am. Ed.] 



A careful examination into the merits of the 
various modes of effecting the radical cure of hy- 
drocele fully establishes the superiority of the 
treatment by injection. The great error formerly 
committed by surgeons in endeavouring to excite 
a high degree of inflammation arose from a mis- 
taken view of the object to be attained ; for not 
perceiving that the exudant secretion could be 
arrested by altering the action of the vessels of the 
part, they thought it necessary to obtain the ob- 



206 SIMPLE HYDROCELE OF THE TESTIS. 

literation of the natural cavity, which, moreover, 
they endeavoured to effect by producing suppu- 
rative inflammation of the membrane, instead of 
by the milder process of adhesion. In recent days, 
surgeons have sought to improve the treatment of 
hydrocele by reducing the amount of inflammation 
to the lowest possible standard, and have nearly 
fallen into the opposite error of suggesting plans 
too mild to be eflicacious and sure. Injection has 
now been largely tried in this and other countries ; 
and experience warrants us in asserting that 
though it is not an infallible remedy, of all the plans 
hitherto practised it combines the greatest number 
of advantages. The pain attending it is slight ; 
its efiects are mild, and at the same time tolerably 
sure ; if properly performed, it is free from danger ; 
and it frequently succeeds without altering the 
natural condition of the parts. I know it is a 
question whether the cure by adhesion, though 
less perfect than that in which the disposition 
merely of the vessels is changed, is not upon the 
whole preferable. In the latter there is a possi- 
bility, if not a probability, of a relapse at some 
future period, many of the causes conducing to 
hydrocele still remaining ; whilst the inconvenience 
produced by an impediment to the free movements 
of the testis, in cases cured by adhesion, is regarded 
as too trivial to be any disadvantage. But, in the 
absence of data* showing the degree to which the 

* These data cannot be readily obtained, since, to be satisfactory, 
the result of the operation must be noted to the close of the patient's 
life. I have lately tapped a hydrocele which had been removed by 



CONGENITAL HYDROCELE. 207 

disease is liable to return after the cure without 
adhesion, I feel perfectly satisfied with such a re- 
sult, and much prefer leaving a patient exposed to 
the doubtful chance of a relapse, than subjecting 
him to severer treatment in order to make sure of 
exciting sufficient inflammation to secure adhesion 
and obliteration of the sac. Injections, however, 
are not capable of effecting a cure in every case, 
nor are they adapted for every constitution. The 
judicious surgeon, therefore, whilst resorting to 
them as his ordinary remedy, will be prepared to 
avail himself, in particular and difficult cases, of 
other means more certain in their effects, such as 
the seton and incision. 



SECTION IL 

CONGENITAL HYDROCELE. 

In simple hydrocele the original communication 
between the cavities of the peritoneum and of the 
tunica vaginalis remains permanently obliterated ; 
but it sometimes happens that fluid accumulates 
around the testis in cases in which the obliteration 
has not been completed, constituting a variety of 
this disease termed congenital hydrocele. The open- 
ing of communication between the two cavities 
is usually small in size, not larger than sufficient 

injection by Sir A. Cooper twenty-five years before, and had not re- 
turned till within the last six months. Sir B. Brodie mentions two 
cases of the return of the disease after injection ; one after the lapse of 
seventeen years, and the other after a period of twenty years. Medi- 
cal Gazette, vol. xiii. p. 93. 



208 CONGENITAL HYDROCELE. 

to admit a crow's or goose's quill. In these cases 
it is difficult to determine whether the fluid is se- 
creted in the abdomen or in the tunica vaginalis ; 
since, if poured out by the peritoneum, it must 
naturally tend to accumulate in the more depend- 
ing cavity. But as the fluid usually becomes 
absorbed after the communication between the 
abdomen and tunica vaginalis has been obliterated 
by the pressure of a truss, it seems probable that 
the fluid is originally formed in the abdomen. 
There is rather a rare variety of congenital hydro- 
cele, in which the testicle is retained in the ab- 
domen or inguinal canal, whilst the peritoneum, 
prolonged for a short distance into the scrotum, 
forms the cyst containing the fluid, which is 
covered only by the integuments and superficial 
fascia. A hydrocele presenting the same characters 
as the congenital sometimes follows a late descent of 
the testicle, unaccompanied with a hernial descent. 
This is also a case of rare occurrence ; but I once 
met with an instance in a lad eighteen years of age. 
Symptoms.- — A congenital hydrocele usually ap- 
pears soon after birth, forming a smooth, transpa- 
rent, fluctuating swelling, which is prolonged into 
the inguinal canal, and receives an impulse when 
the child coughs or struggles. By gentle pressure 
the fluid may be gradually forced up into the abdo- 
minal cavity, and as the tumour disappears the 
testis becomes perceptible in the scrotum. The 
same symptoms are produced by this complaint in 
the adult ; it has also been noticed that the hydro- 
cele is larger at night than when the patient first 



CONGENITAL HYDROCELE. 209 

rises in the morning. M. J. Cloquet observed, in 
two cases of congenital hydrocele in adults, that 
the hand experienced a tremulous and peculiar 
rustling sensation in pressing the fluid into the 
abdomen. "^ 

Diagnosis.— Congenital hydrocele is easily dis- 
tinguished from ordinary hydrocele by the absence 
of a defined boundary to the tumour at its upper 
part ; by the impulse received on coughing ; and 
by pressure, causing the disappearance of the 
swelling, and rendering the testis perceptible. A 
congenital hydrocele might be mistaken for a re- 
ducible intestinal hernia, which also disappears on 
pressure, and dilates and receives an impulse on 
coughing ; but the nature of the disease is indicated 
by the fluctuation and transparency of the swelling, 
and by the absence of the gurgling sound accom- 
panying the return of the intestine. 

Treatment, — In the treatment of congenital 
hydrocele the primary object is to occasion an 
obliteration of the neck of the sac, so as to cut off 
the communication with the abdom.en. For this 
purpose the patient must constantly wear a truss 
made to press firmly on the inguinal canal. After 
adhesion has taken place the fluid usually disap- 
pears : its removal may be encouraged by the 
application of a stimulating lotion, or may be 
effected by acupuncture. This plan is usually suc- 
cessful when adopted in early life; but if after 

* Recherches siir ies Causes et TAnatomie des Hernies Abdomi- 
nales, p. 95. 

27 



210 CONGENITAL HYDROCELE. 

many months' trial it is found to fail, the truss 
should still be worn, not only to prevent the pas- 
sage of fluid from the abdomen into the sac, but 
also to impede a hernial descent, and to afford 
a further chance of obtaining obliteration of the 
opening. This form of hydrocele very rarely re- 
quires injections for its cure, and the operation 
should never be performed unless the surgeon is 
fully satisfied that a communication no longer 
exists between the sac and abdomen. If the sac 
is injected before closure of its neck, peritonitis is 
very liable to ensue, and to endanger the life of 
the patient. Desault, Dupuytren, and other sur- 
geons, after puncturing the sac and evacuating 
the fluid, have injected a stimulating liquid, firm 
pressure being made upon the ring, and continued 
for some time after the operation ; and the practice 
has in some instances been attended with success. 
But in other cases peritonitis has been excited, and 
death has followed. It would not be difficult, by 
a little cautious management, to avoid injecting 
fluid into the peritoneal cavity ; but as the object 
of the operation is to excite inflammation in the 
sac of the hydrocele, the great risk is of the ex- 
tension of the inflammation along the continuous 
serous surface to the peritoneum generally, the 
prevention of which cannot be secured by the 
pressure afterwards maintained at the ring. This 
proceeding, therefore, is not sanctioned by the 
surgeons of the present day; for no one is justi- 
fied in undertaking an operation exposed to such 
danger for the permanent removal of an incon- 



ENCYSTED HYDROCELE OF THE TESTIS. 211 

venience which can be partially remedied by other 
means free from risk. A strong motive for per- 
severing in the attempt to cure congenital hydro- 
cele in early life by means of pressure, is the risk 
of inflammation to v^hich the testis is afterwards 
liable, extending to the sac, and thence to the 
peritoneum in the abdominal cavity, — an inconve- 
nience similar to that remarked in the case of the 
undescended testis. Cloquet examined the body 
of a man aged fifty affected with congenital hernia, 
whose thoracic and abdominal viscera were perfectly 
sound ; but the abdominal cavity contained six 
pints of yellow serum mixed with flocculent al- 
bumen, which appeared to have originated in dis- 
ease of the testis, and the extension of inflammation 
from the tunica vaginalis to the peritoneum.* 




SECTION III. 

ENCYSTED HYDROCELE OF THE TESTIS. 

In encysted hydrocele of the testis, the fluid is 
contained in an adventitious cyst or cysts distinct 
from the sac of the tunica vaginalis. The cyst is 
composed of a thin delicate serous membrane ; it 
maybe developed in three situations: 1, beneath 
that part of the tunica vaginalis investing the epi- 
didymis ; 2, between the tunica vaginalis testis and 
tunica albuginea, which are thus separated from 
each other ; 3, between the layers of the outer or 

* Lib. Cit. p. 144. 



I 



212 



ENCYSTED HYDROCELE OF THE TESTIS. 



loose portion of the tunica vaginalis. The first is 
by far the most common situation, the two latter 
being very rare. These cysts are analogous to the 
aqueous encysted tumours vi^hich are developed in 
the kidney and other parts, the fluid being of a 
similar nature, and differing from that of simple 
hydrocele in being perfectly limpid and colourless, 
and containing no or only a slight trace of albumen, 
so that it does not coagulate on the application of 
heat or by the action of acids. 

1. Small serous cysts not larger than a pea, and 
even smaller, frequently exist immediately beneath 
the tunica vaginalis covering the head of the epi- 
didymis, in which they produce a slight depression. 
In several instances I have found as many as five 
or six perfectly distinct cysts connected with this 

part. Sometimes one or two 
small cysts of this kind are so 
embedded in the substance 
of the epididymis, that they 
cannot be recognised with- 
out dissection. Though these 
minute cysts generally con- 
tain a limpid serum, I have 
found them filled with fluid of 
a milky hue, and I have even 
observed matter like pus 

H. Cysts developed in the epididymis : 
a a. Small cysts slightly elevating the tunica vaginalis. 
h h. Small pedunculated cysts. 

c. Small process or fold of the serous membrane attached at the junc- 
tion of the epididymis to the body of the testis, described at page 36. 




ENCYSTED HYDROCELE OF THE TESTIS. 213 

tinged with blood. These accidental cysts, develop- 
ed in the upper part of the epididymis, sometimes 
project the tunica vaginalis before them until they 
become so far separated from the part where they 
were originally formed, as to be attached only by a 
narrow peduncle formed by the contracted tunica 
vaginalis. Such is the mode of developement of 
those small pendulous pedunculated cysts contain- 
ing an aqueous fluid often found hanging from the 
head of the epididymis, which were erroneously 
supposed by Morgagni to be hydatids. I have on 
many occasions observed them in the different stages 
of their production {vide figure). Thus I have 
seen a pedunculated cyst attached at one part, 
whilst close to it there was a serous cyst precisely 
similar embedded in the substance of the epididy- 
mis. In other instances I have found the cyst very 
prominent, but still connected by a broad attach- 
ment of the tunica vaginalis reflected over it, the 
membrane not having as yet contracted to form the 
narrow neck. In all these cases the prolongation 
of the tunica vaginalis investing the cyst could 
always be demonstrated by a little cautious dis- 
section, and between this membrane and the cyst 
some minute red blood-vessels were generally seen 
ramifying. These pedunculated cysts never acquire 
a large size ; I have seldom found them to exceed 
that of a currant. From the exposed situation of 
the testis, they are liable to be ruptured, the ves- 
tiges of them consisting of fimbriated folds of mem- 
brane ; but this is not a common occurrence. I 



214 ENCYSTED HYDROCELE OF THE TESTIS. 

have seen the delicate peduncle by which the cyst 
was attached as long as three quarters of an inch. 
So common are small serous cysts connected with 
the epididymis in the various states and stages I 
have described, that no one can examine many 
testes without finding them. Now when one or 
more of these cysts, instead of becoming pedun- 
culated, enlarge so as to form an evident tumour 
in the scrotum, they constitute a form of hydrocele 
called, from its original seat, an encysted hydro- 
cele of the epididymis, I have observed this de- 
scription of hydrocele in all its various modifica- 
tions, from the enlargement simply of a single cyst 
to the complication occasioned by the varied dila- 
tation of several of them. In this form of hydrocele 
the epididymis becomes flat- 
tened, and is displaced to one 
side, whilst the testis is found 
either in front of the cyst or cysts, 
or at the bottom of them. It is 
sometimes at the side, but very 
rarely indeed at the posterior 
part of the swelling. In the ad- 
joining wood-cut of a specimen 
which I dissected for the Hospi- 
tal museum, the cyst is above the 
testis, which is so displaced by it 
that its anterior edge is directed 
downwards. The tumour is 
generally of smaller size than a simple hydrocele, 
the fluid seldom exceeding three or four ounces in 




ENCYSTED HYDROCELE OF THE TESTIS. 



215 




quantity. In a case, however, which I saw with 
Mr. Crowdy of Brixton, as much 
as twenty ounces were removed 
from a single cyst. When the 
hydrocele is composed of seve- 
ral cysts, they are seldom of 
large size, but form a cluster 
more or less complicated and 
irregular, according to their 
number. The sacculated ar- 
rangement produced by the de- 
velopement of several cysts may 
be seen in the annexed figure, 
taken from a preparation dis- 
sected by myself: the anterior 
parietes of the cysts are cut away to exhibit their 
interior. The cysts are liable to inflammation, 
which causes a considerable alteration in the qua- 
lity and appearance of the fluid contained in them. 
The fluid may become albuminous, and assume the 
straw or amber colour of ordinary hydrocele ; and 
the cyst may contain lymph, form adhesions, or be 
lined with a false membrane, the fluid being thick 
and turbid. The cysts sometimes also become filled 
with blood, constituting a variety of haematocele. 

2. When a hydrocele forms between the tunica 
albuginea and the inner layerof the tunica vaginalis, 
the cyst is generally single and of small size. As it 
grov/s, it separates the two membranes, which are 
naturally very closely adherent to each other. This is 
a very rare form of hydrocele. I have only met with 
one specimen, which was discovered accidentally 



216 ENCYSTED HIDROCELE OF THE TESTIS. 

after death ; it is represented in the annexed wood- 
cut. The cyst contained about 
two drachms of fluid, and is 
situated along the front of the 
testis ; it is a little thickened. 
One section of it is preserved 
in the museum at the London 
Hospital ; the other I have 
presented to the College of 
Surgeons. Sir B. Brodie has 
described a very similar case. 
A man who died in St. George's 
Hospital was discovered after 
death to have had encysted 
hydrocele of one testicle. The 
cyst was composed of a thin 
membrane, containing a co- 
lourless fluid, and was of about the size of a walnut ; 
it was attached to the anterior part of the testicle, 
below the epididymis. The inner layer of the tunica 
vaginalis was reflected over one side of the cyst, while 
the cyst on the other side rested on the fibrous 
membrane of the tunica albuginea, by which it was 
in consequence separated from the glandular struc- 
ture of the testicle."^ In the museum of St. Thomas's 
Hospital there is a specimen of a small cyst de- 
veloped in the epididymis, which in its subsequent 
growth had extended on the testis, separating the 
tunica vaginalis from the tunica albuginea. 

3. In examining a healthy testis I once found six 

* Lond. Med. and Phys. Journal, vol. Ivi. p. 522. 




ENCYSTED HYDROCELE OF THE TESTIS. 217 

or seven small serous cysts, about the size of currants, 
studding the surface of the loose portion of the tunica 
vaginalis. Two of them were situated in a part of the 
membrane extending up the cord. They projected 
internally, and contained a transparent fluid. I have 
since seen a similar kind of cyst, the size of a large 
pea, in the same portion of the tunica vaginalis. Ac- 
cidental serous cysts have also been observed in the 
sac of a simple hydrocele, and a preparation of this 
kind is contained in the museum of the College of 
Surgeons. If a cyst thus situated were to increase 
to any size, it would constitute a swelling which 
might be appropriately termed an encysted hydro- 
cele of the tunica vaginalis. 

Symptoms, — An encysted hydrocele of the testis 
or epididymis commences imperceptibly, and in- 
creases very gradually, and in general without pro- 
ducing pain. After it has attained a certain size, 
as that of a grape or walnut, its growth is often 
arrested, and it remains stationary for many years, 
causing neither pain nor inconvenience. In this 
state the swelling is perceptible through the scro- 
tum, the testis appearing of an irregular or lobular 
form, or as if it were double. On careful examina- 
tion the cyst may be detected projecting either at 
the upper part, on one side, or behind the testis, 
forming a tense fluctuating tumour, connected with 
the gland, and moving with it. In other cases the 
cyst continues to increase until it forms a tense 
elastic swelling, twice, thrice, or even four times 
the size of the testis, but which seldom becomes so 
large as a simple hydrocele. In tumours of some 

28 



218 ENCYSTED HYDROCELE OF THE TESTIS. 

size the situation of the testis may be ascertained, 
as in simple hydrocele, on examination of the swell- 
ing by means of transmitted light ; by the more 
solid feel of the cyst at one particular part, and the 
peculiar pain experienced there on pressure. This 
form of hydrocele, when large, occasions inconve- 
nience proportionate to its bulk. A swelling be- 
comes apparent through the patient's dress ; it is 
exposed to injury, and feels weighty and uncomfort- 
able. I have observed in two cases of hydrocele of 
the epididymis that more pain was experienced 
than is usual in other forms of hydrocele, the un- 
easiness extending up to the loins, and not being 
relieved by support or the recumbent position, 
which I ascribe to the tension produced by the^^dis- 
tension of the tunica vaginalis reflected over the 
testis, and the more direct pressure thereby made 
on the gland. In these cases the pain was imme- 
diately relieved on puncturing the cysts. 

Diagnosis. — An encysted hydrocele of the testis 
is distinguishable from simple hydrocele by the dif- 
ferent position of the gland, which is generally 
found in front or at one side of the tumour ; by the 
smaller size of the swelling ; and by the limpid and 
colourless character of the fluid evacuated. When 
the hydrocele consists of two or more cysts, fluctu- 
ation and transparency are also less distinct than 
in simple hydrocele. As the position of the testis 
is liable to variation in ordinary hydrocele, the 
nature of the case cannot always be determined 
with accuracy until the cyst has been punctured. 
Treatment, — -An encysted hydrocele of the testis 



ENCYSTED HYDROCELE OF THE TESTIS. 219 

should not be interfered with when of small size 
and unattended with pain or inconvenience* When 
painful or troublesome from its large size, the 
tumour may be removed temporarily by acupunc- 
ture or the trocar, applied either at the back or 
side of the hydrocele, in order to avoid risk of 
wounding the testis, the exact situation of which 
should first be ascertained. The fluid, however, 
generally again collects, and it becomes necessary 
to resort to some method of affording permanent 
relief The radical treatment by injection is not 
found to succeed so well in this variety of the dis- 
ease as in ordinary hydrocele. It frequently fails 
in exciting a sufficient degree of inflammation, and 
cannot well be employed in those cases in which 
several cysts are developed. I prefer myself the 
seton used in the mode recommended at page 190, 
which I have found to be both safe and eflectual : 
it is a plan equally well adapted for the treatment 
of an encysted hydrocele composed of two or more 
cysts, as to one consisting simply of a single cyst. 
The inflammation and constitutional effects are 
usually, however, more severe after an operation 
upon several cysts than when there is only one. 

Mr. Laing, one of the surgeons of the hospital at 
Aberdeen, has published an account of two re- 
markable cases of what he terms " cystic or hyda- 
toid disease of the testis ;" but which I entertain no 
doubt were cases of encysted hydrocele of the epi- 
didymis.* — ^A man, aged twenty-nine, was admitted 

* London Medical Gazette, vol. xxvii. pp. 456, 457. 



220 ENCYSTED HYDROCELE OF THE TESTIS. 

with a large swelling of the left side of the scrotum, 
which was pyriforra, somewhat elastic, had an in- 
distinct fluctuation, but by no means the feel of 
hydrocele. It began several years before without 
any known cause at the lower part of the scrotum. 
The opposite testis was considerably enlarged and 
hard ; and there was a cicatrix at the lower part of 
the scrotum, the result of suppuration two years 
before. An incision was cautiously made through 
the integuments of the scrotum and tunica vagina- 
lis, when a bluish semi-transparent membrane pre- 
sented itself Into this a small trocar was cautiously 
pushed, but only about half an ounce of transpa- 
rent serum escaped. On withdrawing the instru- 
ment another similar membrane appeared, which 
was drawn outwards with dissecting forceps, and 
punctured, and found to contain only two or three 
drachms of serum. In this manner many similar 
cysts were successively drawn forward and opened, 
to the number of upwards of thirty, as the quantity 
of serum amounted to sixteen ounces. The wound 
was then closed with adhesive plaister. The opera- > 
tion was followed by fever, erysipelas of the face, f I 
delirium, and inflammation of the scrotum ; but the 
part healed, and the patient was dismissed cured at 
the end of five weeks. The patient was seen four- 
teen months afterwards, when the testis operated 
on was found quite sound, and not larger than 
natural. — A man aged thirty-five w^as admitted 
with a large tense elastic swelling of the left side 
of the scrotum, neither affected by coughing nor 
change of position, but extending up the cord as 



ENCYSTED HYDROCELE OF THE TESTIS. 221 

far as the abdominal aperture. It gave him little 
uneasiness, unless what arose from its bulk. On 
the whole the symptoms closely resembled those of 
hydrocele ; but the tumour was not transparent, 
and the fluctuation was less distinct. It commenced 
about twelve months ago, without any known cause, 
and extended gradually upwards. An incision was 
cautiously made through the integuments and the 
tunica vaginalis, when a hydatid of considerable 
size presented itself This was punctured, and was 
immediately followed by another, which was also 
punctured, exactly as described in the preceding 
case ; and thus ten or twelve ounces of serum were 
evacuated. When the scrotum was reduced nearly 
to the natural size, the edges of the wound were 
brought together with adhesive plaisters. The 
operation was followed by severe inflammation and 
sloughing of the scrotum, and the wound was not 
healed until two months afterwards. The testis 
was reduced nearly to its natural size. 

It is clear that these were not cases of cystic 
disease of the body of the testis, from the circum- 
stance of the cysts having been exposed without 
division of the tunica albuginea, and the gland 
itself being unaflected, and remaining sound after 
the operation. Those pathologists who have often 
examined the testis after death, and observed how 
frequently small serous cysts, varying in size and 
number, are connected with the epididymis, even 
where nothing of the kind has been detected or 
suspected during life, will readily concur in the 
opinion that such was originally the nature of the 



222 ENCYSTED HYDROCELE OF THE TESTIS. 

disease in these cases. It is rarely, however, that 
so thick a cluster of them increases to so large a 
size. The cases indeed are interesting in several 
points of view ; and the severe effects which followed 
the operation of puncturing them with a trocar 
in both instances will induce practitioners to be 
cautious in thus meddling with similar tumours, 
unless they should become very painful, or enlarge 
to such an extent as to occasion serious incon- 
venience. In October last, a man aged fifty-six, in 
a bad state of health, and suffering from a chronic 
bronchial affection, was referred to me by Dr. 
Aldis, Physician of the London Dispensary, on 
account of a swelling of the left testis. On exa- 
mination I found the testis situated at the lower 
part of the scrotum ; and immediately above the 
gland, and connected with it, two distinct fluctuating 
cysts, each somewhat larger than the testis, which 
together produced a considerable lobular swelling. 
The cysts proved to be distinct, fluctuation not 
being communicable from one to the other. The 
patient stated that the swellings had been forming 
between seven and eight years, but had only latterly 
given him pain. I easily recognised the affection 
to be encysted hydrocele of the epididymis. Two 
punctures were made with a cataract needle in 
each of the cysts. A few drops of pellucid serum 
escaped, and next day I found the two swellings 
above the testis entirely removed ; the man also 
expressed himself much relieved. There was, 
however, a third cyst, the size of a filbert, with 
which I did not think it necessary to interfere. 



DIFFUSED HYDROCELE. 223 

The cysts again filled with fluid, and as they be- 
came tense the pain returned. As the patient's 
health did not admit of the performance of any 
operation for his permanent relief, I again punc- 
tured the cysts, and with the same result as before ; 
and he has since continued to apply to me about 
every hve or six weeks to have the operation re- 
peated. 

SECTION IV. 

DIFFUSED HYDROCELE OF THE SPERMATIC CORD. 

Mr. Pott has given an admirable account of this 
affection, under the denomination of hydrocele of 
the cells of the tunica communis.^ It has likewise 
been particularly described by Scarpa.t The dis- 
ease is of the nature of simple oedema, a watery 
fluid being diffused throughout the cellular tissue 
connecting the vessels of the spermatic cord, and 
enclosed in a cellular sheath, which is invested by 
the musculo-aponeurotic structure of the cremaster 
muscle. On dissection the sheath is found dis- 
tended, and when the complaint has lasted for some 
time, more or less thickened. The cellular tissue 
beneath is infiltrated with a limpid albuminous 
serum of a white or yellowish colour, which flows 

* Vide his Treatise on Hydrocele. 

t Memoria sull' Idrocele de Cordone Spermatico. Bertrandi, an 
Italian surgeon, in a memoir published by the French Academy of 
Surgery in 1778, has given an accurate description of this affection 
which, however, he did not sufficiently distinguish from the encysted 
hydrocele of the cord. He dissected on the dead body a diffused 
hydrocele which contained twenty ounces of fluid. 



224 



DIFFUSED HYDROCELE OF 



out in the course of the dissection. It is owing to 
the confinement of the fluid by this investing 
sheath that the swelling assumes an uniform sur- 
face and definite shape. The cells infiltrated with 
serum, which in their natural state are scarcely 
visible by the unassisted eye, are converted into 
large vesicles, some of which are big enough to 
admit the end of the finger. These cells appear 
larger and more delicate towards the base of the 
swelling, where they sometimes disappear alto- 
gether ; so that there is only one considerable 
cavity, the fluid having a tendency to collect to- 
wards the lowest and most depending part, and to 
form a fluctuating tumour there. The base of the 

swelling corresponds to 
the point at which the 
spermatic vessels join 
the testicle, and at this 
part a dense septum 
cuts off all communi- 
cation with the tunica 
vaginalis. In some in- 
stances the efliasion 
extends along the cord 
into the abdomen, as in 
a remarkable case re- 
lated by Mr. Pott, which 
will be presently de- 
scribed. In the annex- 
ed figure of this af- 
fection, taken from 
Scarpa, the sheath of 




THE SPERMATIC CORD. 225 

the cremaster is laid open, exposing the pyramidal 
swelling enclosed in its firm cellular envelope. The 
testis and tunica vaginalis are seen below it. In 
general anasarca the cellular membrane of the 
spermatic cord is frequently distended with serum, 
as well as the scrotum ; but oedema of the cord alone 
is certainly a very rare affection. Sir A. Cooper 
makes no allusion to it in his work on the diseases 
of the testis ; and Mr. Pott, to whom we are in- 
debted for so good and accurate a description of 
this species of hydrocele, probably met with a 
greater number of cases of it than have occurred 
in the practice of any surgeon since his day. 
Causes obstructing the return of blood from the 
testis, as induration and enlargement of the glands 
in the course of the cord, would conduce to its 
production. I have observed a slight oedema of 
the cord in two or three instances after acute or- 
chitis, but it always disappeared as the inflamma- 
tion subsided. The affection is said to have been 
induced by the pressure of a truss applied for the 
cure of an inguinal hernia. 

Symptoms. — Mr. Pott thus describes the ap- 
pearance and symptoms of this affection. He says, 
" In general, while it is of moderate size, the state 
of it is as follows. The scrotal bag is free from all 
appearance of disease ; except that when the skin 
is not corrugated it seems rather fuller, and hangs 
rather lower on that side than on the other, and if 
suspended lightly in the palm of the hand feels 
heavier: the testicle with its epididymis is to be 
felt perfectly distinct below this fulness, neither 

29 



226 DIFFUSED HYDROCELE OF 

enlarged, nor in any manner altered from its na- 
tural state : the spermatic process is considerably 
larger than it ought to be, and feels like a varix, 
or like an omental hernia, according to the diffe- 
rent size of the tumour ; it has a pyramidal kind of 
form, broader at the bottom than at the top : by 
gentle and continued pressure it seems gradually to 
recede or go up, but drops down again immediately 
upon removing the pressure, and that as freely in 
a supine as in an erect posture : it is attended with 
a very small degree of pain or uneasiness, which 
uneasiness is not felt in the scrotum, where the 
tumefaction is, but in the loins. If the extravasa- 
tion be confined to what is called the spermatic 
process, the opening in the tendon of the abdominal 
muscle is not at all dilated, and the process passing 
through it may be very distinctly felt ; but if the 
cellular membrane which invests the spermatic 
vessels within the abdomen be affected, the ten- 
dinous aperture is enlarged, and the increased size 
of the distended membrane passing through it 
produces to the touch a sensation not very unlike 
that of an omental rupture.""^ At its commence- 
ment the tumour is of a cylindrical form ; but at a 
later period, and as it increases in size, it becomes 
pyramidal, especially when the patient is in the 
erect posture. By altering his position to the 
recumbent, the form of the tumour is slightly 
changed : it becomes more oblong, and nearly of 
equal dimensions from the ring to the testis. How- 

* Lib. cit. p. 370, 



THE SPERMATIC CORD. 227 

ever much the swelling may increase, it has been 
remarked that the 'penis never appears so much 
retracted as in simple hydrocele of equal size. 

Diagnosis. — An omental hernia, or an encysted 
hydrocele of the cord, might be mistaken for a dif- 
fused hydrocele of the spermatic cord. In regard 
to the former, Scarpa observes, that "the diffused 
hydrocele of the cord, when it enters into the ring, 
resembles an omental hernia so closely that it is 
very difficult to distinguish the two complaints. 
Both have a cylindrical form, and extend into the 
ring. They are similar in consistence and degree 
of sensibility, as well as in the difficulty expe- 
rienced in returning them. Pott represents that 
the omentum, when returned, remains in the ab- 
domen until the patient assumes the erect position, 
or makes some e^oxi ; while the swelling in diffused 
hydrocele comes back immediately. I have found, 
however, that the omentum comes down quickly in 
some omental herniae, and that the swelling, when 
pushed up, does not reappear immediately in some 
cases of diffused hydrocele. I have observed that 
the swelling is firmer and more irregular on the 
surface in the epiplocele than in the watery effusion ; 
and that the latter is larger below than above, while 
these proportions are reversed in the rupture."^ 
Mr. Lawrence remarks, that " The distinction of 
the two cases must rest on the following points : — 
the impulse on coughing in the rupture ; the com- 



* Sull Ernie, Mem, 1, \ xxxii. ; quoted from Lawrence on Hernia, 
5th edit, p. 251. 



228 DIFFUSED HYDROCELE OF 

plete removal of the swelling, and the sense of the 
omentum passing up into the abdomen ; its visi- 
ble and tangible escape from the cavity when the 
rupture is brought down again by coughing, and 
the free natural condition of the cord and ring 
when the swelling has been replaced. The fluctu- 
ation of the watery tumour at its lower part ; the 
absence of impulse in coughing ; its imperfect re- 
moval under pressure, so that the cord can never 
be felt in a natural state ; and sometimes a visible 
enlargement of the inguinal canal and its neigh- 
bourhood when the fluid is pressed upwards.'"^ An 
irreducible epiplocele would be even more liable to 
be mistaken for a diffused hydrocele, as some of 
these distinguishing marks would be absent. In 
cases of much difficulty and doubt, the surgeon 
must be guarded in pronouncing an opinion, and 
very cautious in adopting any operation. Scarpa, 
indeed, frankly confesses the imperfection of our 
art with respect to the diagnosis in these cases.t 

Diffused hydrocele is distinguished from encysted 
hydrocele of the cord by the pyramidal and some- 
what diffused form of the swelling, which extends 
to the ring ; by the alteration in shape producible 
by pressure ; and by the absence of fluctuation in 
its upper part. 

As the testis is perceptible in diffused hydrocele 
of the cord, this disease cannot well be mistaken 
for simple hydrocele. Nor is diffused hydrocele 
likely to be confounded with varicocele, the cha- 

* Lib. cit. p. 252. + Treatise on Hernia, tr. by Wishart, p. 99. 



THE SPERMATIC CORD. 229 

racteristic symptoms of the latter being too evident 
to allow of the intelligent surgeon erring in his 
diagnosis of these affections. 

Treatment. — In regard to the treatment of dif- 
fused hydrocele of the cord, Mr. Pott observes, 
*' While it is small it is hardly an object of surgery, 
the pain or inconvenience which it produces being 
so little that few people would choose to submit to 
an operation to get rid of it, and it is very seldom 
radically curable without one : but when it is large, 
or affects the membrane within the cavity as well 
as without, it becomes an apparent deformity, is 
very inconvenient both from its size and weight ; 
and the only method of cure which it admits is far 
from being void of hazard ; as must appear to every 
one who will consider, or who is at all acquainted 
either with the nature of lymphatic extravasation 
or absorption, or with the frequent consequences of 
wounds inflicted on parts merely membranous.'"^ 
This form of hydrocele admits of temporary if not 
permanent relief, with perhaps less risk than was 
supposed by Mr. Pott. For, as the cells commu- 
nicate freely, it is not necessary to make a large 
incision for the removal of the fluid, one or two 
acupunctures in the depending part of the tumour 
being sufl[icient to enable the fluid to escape into 
the cellular tissue of the scrotum, from which it will 
soon be removed by absorption. The danger of 
free incisions into the distended cellular tissue arises 
from their being liable to excite diffuse inflamma- 

"^ Lib. r.it. p. 371. 



230 ENCYSTED HYDROCELE OF 

tion, which is apt to spread along the cord to the 
cellular tissue of the pelvis, and end in gangrene, 
especially in persons of impaired constitution. Both 
Scarpa and Pott have witnessed instances in which 
the operation of incision has proved fatal. The 
latter surgeon has related a remarkable case of dif- 
fused hydrocele, in a man aged thirty-five, of such 
prodigious size that it hung more than half way 
down to the patient's knee, and formed a considera- 
ble tumour in the inguinal region. The diagnosis 
was extremely difficult. An incision was made into 
it, and eleven Winchester pints of water were 
drained off. The fluid collected again ; and Mr. 
Pott divided the whole scrotum from the bottom 
upwards, from which operation the patient died.^ 



SECTION V. 

ENCYSTED HYDROCELE OF THE SPERMATIC CORD. 

This term is applied to a tumour caused by the 
developement of a cyst containing fluid in the loose 
cellular tissue of the spermatic cord. The cyst is 
formed of a thin transparent membrane possessing 
the ordinary characters of a serous membrane ; and 
its contents consist in general of a limpid aqueous 
liquid containing little or no albumen, but some- 
times of a straws-coloured serum, similar to the fluid 
of simple hydrocele. It is of an oval form ; and its 
size, though variable, seldom exceeds that of a hen's 

* Lib. cit. Case X. p. 377. 



THE SPERMATIC CORD. 231 

egg, and is usually smaller. It is loosely attached 
by cellular tissue to the vessels of the cord, which 
become separated and displaced by it, but are 
situated at its posterior part. The cyst is invested 
by the common integuments, superficial fascia, mus- 
culo-aponeurotic sheath of the cremaster muscle, 
and fascia transversalis. It may occur either im- 
mediately above the scrotum in the middle of the 
cord, or just below the abdominal ring, and it has 
been met with within the inguinal canal. Usually 
there is a single cyst ; but occasionally several are 
developed, and a chain of them has been formed 
along the cord. The cyst and its contents are 
liable to changes consequent upon inflammation. 

Encysted hydrocele of the cord appears to origi- 
nate in general in a partial or imperfect obliteration 
of the prolongation of peritoneum, drawn down at 
the period of the descent of the testis. At page 35 
I have described the different appearances presented 
by the remains of this prolongation, which, it has 
been remarked, sometimes consist of a single cyst, 
or of two or more sacculi moistened by a serous 
fluid. When this fluid accumulates in any quantity, 
an encysted hydrocele is the result. Such is the 
mode of origin of this affection when occurring in 
infants. I believe that in adults it is frequently, if 
not generally, produced in the same way. M. J. 
Cloquet has remarked, that the remains of the 
peritoneal process, accompanying the descent of the 
testicle, were met with in male subjects of all ages : 
and he mentions, as a singular circumstance, that 
they were nearly as frequently found in the old as 



232 



ENCYSTED HYDROCELE OF 



in the young subject.* My own dissections agree 
with the observations of this accurate anatomist. 
In the museum at the London Hospital there is a 
preparation showing the tunica vaginalis continued 
for about two inches up the cord, and immediately 
above it an encysted hydrocele which was taken 
from an adult subject. — In dissecting the body of 
a man aged eighteen, who died of pneumonia, I 
found an encysted hydrocele of the cord above the 
testis in close contact with the tunica vaginalis. 
Immediately above this cyst, but quite distinct from 
it, there was a narrow and empty serous sac three 
inches in length, with a con- 
tracted neck, and communi- 
cating with the abdomen. 
They are figured in the ac- 
companying engraving, with 
the hernial sac laid open, 
and part of the parietes of 
the encysted hydrocele cut 
away to expose their interiors. 
The position of the testis is so 
changed that its anterior bor- 
der is directed downwards. — 
In the examination of the body 
of a man who died of disease 
of the heart, I found on the 
ri^ht side a thickened and 
empty serous pouch, extend- 
ing for about an inch and a 




'y 



F^' 



* Description of the Parts concerned in Inguinal and Femoral 
Hernia, tr. by ^M'Whinnie, p. 25. 



THE SPERMATIC CORD. 233 

half below the external abdominal ring. Directly 
below it was an independent cyst, capable of con- 
taining a walnut, similar in structure to the her- 
nial sac, but lined by a thin false membrane. The 
tunica vaginalis, which was healthy in structure, 
extended up the cord as far as the cyst, from which 
it was separated by a thick and firm partition. — 
In opening the body of a sailor who died with 
ascites, I noticed at the internal ring a small, deli- 
cate, transparent, pedunculated cyst, not larger 
than a nut, projecting into the cavity of the ab- 
domen. The spermatic cord below appearing full, 
I made an incision into it, and found a large serous 
cyst exactly resembling the peritoneum in struc- 
ture, which extended into the inguinal canal, and 
contained a small quantity of transparent fluid. 
Observing a small orifice at its upper part, I intro- 
duced the point of a blow-pipe ; it passed into the 
centre of the pedunculated cyst, which was thus 
shown to be a process from the cyst connected with 
the cord. In Section 6 of this Chapter, I have 
described and given a representation of an inguinal 
hernia, combined with an elongated encysted hydro- 
cele of the cord ; and in Chapter V., Section 2, I 
have related a case of encysted haematocele of the 
cord, in which the tunica vaginalis remained un- 
obliterated as far up as the cyst, whilst a hernial 
sac is situated immediately above it. These dissec- 
tions confirm the view that has been taken of the 
more general mode of origin of encysted hydrocele 
of the spermatic cord. In two or three instances, 
however, I have found a small, thin, delicate serous 

30 



234 ENCYSTED HYDROCELE OF 

cyst in the loose cellular tissue of the cord, very 
like the cysts sometimes developed in the cellular 
tissue of the neck and in other parts, which very 
probably originated independently, and had no con- 
nexion with the process of peritoneum consequent 
on the descent of the testis. 

Symptoms. — An encysted hydrocele of the sper- 
matic cord is seldom discovered until it has attained 
some considerable size, its formation being imper- 
ceptible, and unattended with pain or inconvenience. 
It produces a swelling in the spermatic cord, which 
is of an oval and defined form, and distinct from 
the testis, which feels even and tense, and has a 
manifest fluctuation, and may be handled freely 
without pain, and which is more or less trans- 
parent, and quite movable upwards and down- 
wards. The distance of the tumour from the 
abdominal ring and testis varies in different cases, 
and is liable also to temporary alterations from the 
irregular contractions of the cremaster muscle. 
The vessels forming the spermatic cord can gene- 
rally be traced to the posterior part of the cyst. 
This affection is met with most commonly in 
infants, and I have seen it as early as a fortnight 
after birth ; but it occurs at all periods of life. 

Diagnosis. — An encysted hydrocele of the cord 
is liable to be mistaken for a simple hydrocele, and 
for a hernia. In both instances the diagnosis may 
generally be made without difficulty. It is distin- 
guished from simple hydrocele by the tumour being 
felt distinct from the testis, and by its being situ- 
ated higher up in the scrotum, and above the gland. 



THE SPERMATIC CORD. 235 

When the cyst is of large size the diagnosis may 
be less easy, in consequence of the testis being 
partly imbedded in the tumour ; but, by a careful 
examination, the gland may always be distinguished 
independent of the hydrocele. 

This affection differs from hernia in the uniform 
size and defined shape of the tumour, which does 
not extend upwards to the ring ; in being trans- 
parent, very movable, and receiving no impulse on 
coughing ; and in the absence of the gurgling sen- 
sation, and other symptoms usually attendant on 
ruptures. When of small size, and situated near 
the abdominal ring, the tumour may admit of being 
pushed upwards into the inguinal canal, a circum- 
stance which renders the diagnosis rather difficult. 
The facility, however, with which the vessels of the 
cord can generally be felt when the tumour has 
descended again, and the parts between the swell- 
ing and the ring are grasped between the finger 
and thumb, will enable the surgeon to ascertain the 
nature of the case. But if, as sometimes happens, 
the cyst be situated within the inguinal canal, or 
at the opening of the external abdominal ring, it is 
extremely difficult to distinguish the swelling from 
a hernia ; for it disappears under pressure, is very 
apparent when the patient is in the erect position, 
and is removed or is less manifest when he is in the 
recumbent posture. The diagnosis will be facili- 
tated by observing that although the tumour can- 
not be made to descend below the external ring, 
neither can it be thrust completely into the abdo- 
men like a portion of intestine. The cyst being 
lodged in the inguinal canal, there must still be a 



236 ENCYSTED HYDROCELE OF 

tumour in the groin behind the tendon of the ex- 
ternal oblique muscle, which, though somewhat 
obscure, will yet be perceptible- to the eye and 
fingers of the adroit surgeon. 

Treatment, — In children, encysted hydrocele of 
the cord, like simple hydrocele, often and indeed 
generally disappears spontaneously, so that surgi- 
cal interference is seldom required for its removal. 
It is frequently, however, a source of uneasiness to 
parents, who are apt to apprehend the existence of 
a rupture. The surgeon may therefore safely 
assure them, not only that it is a complaint of 
slight importance, but that if it does not vanish of 
its own accord, or by the application of a stimu- 
lating lotion, an operation comparatively trifling 
will effectually remove it whenever it attains such 
a size as to be productive of inconvenience. But 
it is better not to interfere with an encysted hydro- 
cele of the cord, either in children or adults, so 
long as it is of small size and unattended with pain. 

In the first instance a stimulating lotion may 
be directed to be constantly applied to the part. 
Should the tumour not disperse in the course of 
two or three weeks under this treatment, and con- 
tinue to be a source of annoyance from its bulk, it 
may be punctured in two or three places with a 
cataract needle, and the fluid pressed out into the 
surrounding cellular tissue. In many instances, 
especially at an early period of life, this proves a 
permanent remedy. But if the swelling returns, 
and it does so generally in the adult, other measures 
must be resorted to. 

The radical cure of encysted hydrocele of the 



THE SPERMATIC CORD, 237 

spermatic cord may be effected in various ways. 
Excision of a portion of the cyst, incision, the 
seton, the tent, and injection have all been em- 
ployed for the purpose. The injection of the 
cyst of an encysted hydrocele is a plan of treat- 
ment which is not in much favour with practical 
surgeons. There is more difficulty in perform- 
ing the operation, and a greater risk of the fluid 
being forced into the surrounding cellular tissue, 
than in the injection of the enlarged tunica vagi- 
nalis, and the operation is not so generally success- 
ful as in the latter form of hydrocele. Mr. Hey, 
of Leeds, used with success the following method, 
which is similar to that proposed by Mr. Douglas 
for the cure of simple hydrocele : — " The operator 
must grasp the integuments and spermatic cord in 
his left hand at the posterior part of the tumour, 
till he makes it project and draws the skin tight 
over it. He must then divide the skin and layers 
of fascia longitudinally, by repeated gentle strokes 
of the knife, till he arrives at the cyst, which is 
generally quite transparent. The projection of the 
cyst increases as the parts which cover it are 
divided ; and when it is laid bare almost the whole 
of it is exposed. The cyst is then punctured with 
a lancet, and all that appeared perfectly transparent 
before the puncture, must be cut off with the knife 
or scissors. The posterior part of the cyst must be 
left untouched. After the extirpation of the trans- 
parent part of the cyst, the integuments should be 
brought over the spermatic cord, and united by the 
interruptured suture, otherwise they are apt to 



238 ENCYSTED HYDROCELE OF 

shrink back, and leave the cord projecting out of 
the wound."* This is a very certain mode of treat- 
ing the disease ; but I prefer the seton, the effects 
of which are less severe than those of incision, 
whilst the plan is equally effectual. The surgeon 
may proceed as follows: — Let the scrotum be tightly 
grasped with the left hand, so as to render the 
tumour tense and prominent. Then let a large- 
sized curved needle armed with a double silk liga- 
ture be introduced at the lower part of the swell- 
ing, and brought out above at a distance of an inch 
and a half or two inches from the part where it was 
introduced, and the ends tied together to prevent 
the seton escaping. The fluid will afterwards 
dribble away along the silk, and in a few days after 
the operation, and perhaps in twenty-four or thirty- 
six hours, sufficient inflammation will be esta- 
blished. The threads can then be withdrawn, after 
which the cyst becomes permanently obliterated by 
adhesion, no other trace of it remaining but a slight 
induration at the part, which disappears completely 
in a short period. This I have found to be an 
effectualand safe proceeding. In cases of encysted 
hydrocele very high up, the surgeon must bear in 
mind the near proximity of the cyst to the peri- 
toneum, and the consequent risk of the extension 
of the inflammatory action to this important struc- 
ture. He must be careful not to excite too active 
inflammation. It appears that operations on cysts 
developed in the spermatic cord are liable to excite 

* Practical Observations on Surgery, p. 559. 



THE SPERMATIC CORD. 239 

diffuse inflammation of the cellular tissue of the 
part. Mr. Pott has related a case treated by inci- 
sion which proved fatal on the seventh day, from 
inflammation extending to the cellular tissue of 
the pelvis and loins. The subject of the operation 
was, however, in a bad state of health.* I have 
lately been informed by my friend Mr. Morton, of 
University College Hospital, of a case in which 
such severe inflammation of the cellular tissue suc- 
ceeded the introduction of a seton, composed of a 
single thread of silk, through an encysted hydrocele 
in the spermatic cord of a boy, that suppuration 
took place in the iliac fossa, and for a time en- 
dangered the patient's life, though he finally re- 
covered. 

SECTION vi. 

COMPLICATIONS OF HYDROCELE. 

The following are the principal complications of 
hydrocele : 

1. Simple hydrocele, combined with encysted 
hydrocele of the testis. 

2. Simple hydrocele, combined with encysted 
hydrocele of the spermatic cord. 

3. Simple hydrocele, combined with diffused 
hydrocele of the spermatic cord. 

4. Oscheo-hydrocele, including both simple hy- 
drocele and encysted hydrocele of the cord, com- 
bined separately with inguinal hernia. 

* Lib. cit. Case XIV. p. 390. 



240 COMPLICATIONS OF HYDROCELE. 

1. The first is not an uncommon complication. 
In the dissection of these parts I have often found 
the tunica vaginalis distended with three or four 
drachms, and even an ounce or two of serum, two 
or more small distinct aqueous cysts being at the 
same time connected with the upper part of the 
epididymis ; and I have twice met with this com- 
plication on both sides in the same individual. 
The small adventitious cysts appear to be the 
original disease, the irritation produced by them 
being the cause of the increased quantity of fluid 
in the tunica vaginalis. The tumour formed by 
the combined cysts is in some cases smooth, and in 
others irregular, according to their relative size. 
When the quantity of fluid effused in the tunica 
vaginalis is only small, this complication may some- 
times be distinguished during life ; but when the 
amount is considerable, the distension of the tunica 
vaginalis completely masks the cysts developed in 
the testis or epididymis, rendering it impossible for 
the surgeon to detect the nature of the case. They 
sometimes attain so large a size as to require the 
fluid to be removed, and some of the cases of 
operation on multilocular hydrocele mentioned by 
writers, I believe to have been instances of this 
complication. It sometimes happens in a case of 
this kind, that when the trocar is introduced at 
the anterior part of the swelling a quantity of pale 
straw-coloured serum is drawn off* ; but the tumour 
is only diminished, not removed. If, however, the 
trocar be afterwards passed into the fluctuating 
swelling which still remains, exit is given to a 



COMPLICATIONS OF HYDROCELE. 241 

limpid fluid which does not coagulate on the appli- 
cation of heat. 

2. Simple hydrocele, combined with encysted 
hydrocele of the spermatic cord, is somewhat rare. 
The swelling produced by the accumulation in the 
tunica vaginalis is below and rather in front of the 
tumour in the spermatic cord, and a well-defined 
furrow in the scrotum generally marks the boun- 
dary between the two. In the pathological col- 
lection at the London Hospital, there are two 
specimens of a collection of fluid in the tunica vagi- 
nalis associated with an encysted hydrocele of the 
spermatic cord. In one of them, the tunica vagi- 
nalis has remained unobliterated for about two 
inches along the spermatic cord, and the encysted 
hydrocele is seen immediately above it. In the other 
preparation, it is apparent that both sacs have been 
the seat of inflammation, false membranes being 
contained within them, and the testis being a good 
deal enlarged. A child six years of age came 
under my care at the Hospital on account of a large 
hydrocele on the right side, which extended up- 
wards nearly as high as the abdominal ring. 
Three acupunctures were made in the tumour, and 
in ten days the whole of the fluid had disappeared ; 
but observing a small swelling still remaining in 
the direction of the spermatic cord, I made a 
further examination, and detected an encysted 
hydrocele of the cord just above the testis, which 
had previously been concealed by the fluid collected 
in the vaginal sac. The skin covering it was 
painted with a strong solution of iodine twice a 

81 



242 



COMPLICATIONS OF HYDROCELE. 



week ; but not disappearing so quickly as I wished, 
it was afterwards punctured with a. needle. The 
acupuncture was repeated two or three times, and 
in a fortnight the encysted hydrocele of the cord 
was removed, and I believe did not return. A case 
of this complication, in an infant not many weeks 
old, is recorded in the London Medical Gazette.^ 

3. Simple hydrocele, associated with diffused 
hydrocele of the cord, is also a rare complication. 
The chief marks of the complaint are, the remark- 
able volume of the neck of the tumour, with a 
dilated state of the abdominal ring ; the irre- 
gular form of the swelling ; and the existence 
of a furrow passing obliquely 
on the anterior part of the 
scrotum, corresponding to the 
superior margin of the dis- 
tended vaginal coat, and being 
higher or lower according to 
the amount of the fluid ac- 
cumulated within it. Simple 
hydrocele of the hour-glass 
form exhibits a double tumour 
divided by a furrow ; but the 
swelling is defined above, and 
has no neck, and fluctuation 
is communicable from one to 
the other. Any doubt in regard 
to diagnosis in a case of this 
kind may be cleared up by a 




I. Simple hydrocele combined with diffused hydrocele of the cord. 
After Scarpa. 1 — 1. Furrow marking' the division between the tumours. 
* Vol. xxix. p. 757. 



COxMPLICATIONS OF HYDROCELE. 243 

puncture made into the anterior tumour, when, 
after the water collected in the tunica vaginalis has 
escaped, the swelling occasioned by the diffused hy- 
drocele of the cord will still remain undiminished. 

Encysted hydrocele, combined with simple hy- 
drocele, is also distinguished from the present 
complication by the defined form of the tumour 
above ; and from a simple hydrocele of the hour- 
glass form, by fluctuation being limited to the 
separate swellings. 

4. Oscheo-hydrocele. — It is remarked by Mr. 
Lawrence, that " Scrotal hernia is combined not 
unfrequently with hydrocele, each disease being 
marked by its peculiar symptoms. A close ex- 
amination may be necessary, in order to detect the 
true nature of the case. The hydrocele and the 
rupture may form two distinct swellings, an upper 
and a lower one ; or they may meet together, the 
distinction being marked externally by a constric- 
tion ; or they may be completely blended into one 
swelling, without any distinction recognisable ex- 
ternally. In the latter case, their relative situations 
might be expected to depend on the order of their 
occurrence. If the rupture should have taken 
place after the formation of the hydrocele, we might 
expect the former to descend in front of the latter. 
On the contrary, if fluid should be eflused into the 
tunica vaginalis of a ruptured patient, the swelling 
would probably rise in front of the rupture. Mr. 
Stanley met with two instances in which hydrocele 
was placed directly before scrotal hernia, and the 
component parts of the spermatic cord were sepa- 



244 COMPLICATIONS OF HYDROCELE. 

rated by the tumour, which seemed to have been 
forced between them. These specimens, with three 
others, are preserved in the museum of St. Bartho- 
lomew's Hospital. In all five the hydrocele is in 
front of the rupture, and in most of them it ascends 
nearly to the ring. The same relative position of 
the two diseases has been observed by others, and 
may therefore be considered as the ordinary ar- 
rangement."* A voluminous hydrocele, if unsup- 
ported, appears to be highly favourable to the oc- 
currence of hernia and the extension of the sac, by 
dragging down the peritoneum. M. J. Cloquet dis- 
sected the body of an old man, the subject of ex- 
ternal inguinal hernia on the right side. The sac 
was four inches in length ; its orifice was large and 
rounded, and its cavity was separated into two 
parts by a fibrous projecting ring. Below the latter 
the peritoneum was thick, whitish, and very adhe- 
rent to the external coverings ; above, it was thin 
and transparent, as in the abdomen. The descent 
of the fibrous ring, and consequently the elongation 
of the sac, appeared to be owing to the weight of 
a voluminous hydrocele of the tunica vaginalis, 
which intimately adhered to the lower part of the 
hernial tumour. A fold of small intestine, two 
inches and a half long, and unadherent, occupied the 
upper division of the sac. M. Cloquet has related 
the particulars of another case of inguinal hernia, 
complicated with a very large hydrocele, in which 
he observed, on raising the tumour and gently 

* Treatise on Ruptures, 5th edit. p. 256. 



COMPLICATIONS OF HYDROCELE. 



245 



drawing up the peritoneum of the abdomen, that 
the hernial sac receded and diminished in extent. 
The sac contained omentum, which was reducible, 
and the hernia was situated behind the hydrocele.* 
If the rupture were occasioned by the weight and 
traction of the hydrocele, as is evidently presumed 
by M. Cloquet, this case would tend to invalidate 
the conclusion of Mr. Lawrence, in respect to the 
relation of the parts, when the hernia succeeds the 
formation of the hydrocele. The occurrence of 
these two diseases is not an uncommon complica- 
tion ; in most of the cases which I have met with 
the hydrocele w^as placed below, and free of the 
rupture, and in a few only in front of it. I have 
never found the hernial sac cover- 
ing the forepart of a hydrocele. 
The ordinary relations of hydro- 
cele and scrotal hernia may be 
seen in the accompanying wood- 
cut. In the figure at page 146 
the sac of an inguinal hernia is 
represented at some little distance 
above a small hydrocele. Dupuy- 
tren states it sometimes occurs, 
when ^ hydrocele is placed in 
front of a hernia, that a part of 
the omentum or intestine descends into a cyst, 
which projects into the hydrocele, and is formed of 
the hernial sac and serous fold of the tunic of the 




* Recherches Pathologiques sur les Causes et I'Anatomie des 
Hernies Abdominales, p. 22. 



246 COMPLICATIONS OF HYDROCELE. 

testis. Oat of six cases of this kind which came 
under his observation, in two instances he found 
symptoms of strangulation to depend on constric- 
tion at the part where the viscera were engaged in 
the serous pouch of the testis."^ This complication 
is of the nature of the hernia infantilis, described by 
Mr. Hey, and called by Sir A. Cooper encysted hernia 
of the tunica vaginalis. 

The co-existence of hernia and hydrocele does 
not in general constitute an objection to the per- 
formance of the radical operation for the latter. 
But the surgeon should be particularly cautious 
not to excite too much inflammation ; and in cases 
where the contiguity of the two sacs is close and 
extensive, and in those in which the hernial sac 
projects into the hydrocele, he should recommend 
the patient to be content with the palliative treat- 
ment. The hernia should always, if possible, be 
reduced before the tunica vaginalis is punctured. 

Scarpa has described a case of strangulated in- 
guinal hernia, complicated with encysted hydrocele 
of the spermatic cord, in which it was necessary to 
operate. A student about twenty-nine years of 
age was attacked with symptoms of incarcerated 
hernia. He had been subject to a rupture on the 
left side of the scrotum for more than fifteen years, 
but had not been able to fit a proper bandage. The 
hernia was tense, and above the moderate size, and 
the bottom of the tumour was unusually raised, 
and as it were pushed upwards, by a body situated 

* Lecons Orales, Brussels edit, t. iv. p. 233. 



COMPLICATIONS OF HYDROCELE. 247 

behind the hernia ; which body was undoubtedly 
not the testicle, as the gland was felt distinctly by 
the touch in the bottom of the scrotum, and lower 
down than the hernia. The symptoms being very 
urgent, the patient was operated on in Scarpa's 
presence. The hernial sac was found to contain 
a very small quantity of water, and a loop of small 
intestine slightly tinged of a brown colour, and 
about three or four inches in length. After divi- 
sion of the neck of the hernial sac and the ring, 
and also after reduction of the intestine, there still 
remained externally a soft tumour, elastic, and 
evidently full of fluid. An incision was made into 
this tumour, and a considerable quantity of serous 
fluid discharged. At the bottom there appeared 
a vesicular gelatinous substance, which was cut 
away; and it was clearly perceived that the in- 
testinal scrotal hernia was accompanied posteriorly 
with an encysted hydrocele of the spermatic cord. 
In the course of six weeks the patient was 
completely cured of both these diseases.* This 
is a very rare complication : I have met with it 
in only two instances ; in both on the right side. 
The patients were adults. In one, who died of 
peritoneal inflammation, with the hernia unreduced, 
I had an opportunity of making a careful dissection 
of the parts. The hernial sac was greatly thickened, 
and coated with lymph, and contained a small fold 
of intestine surrounded by turbid serum. Directly 
below it there was a hydrocele of the cord of an 

* Treatise on Hernia, tr. by Wishart, p. 23L 



248 



COMPLICATIONS OF HYDROCELE. 



1 



oblong shape, and more than two inches in length, 

the parietes of which dif- 
fered from the hernial sac 
in being thin and transpa- 
rent. The testis hung lower 
than natural, and was so 
displaced that its antero- 
inferior edge presented 
directly downwards (see 
figure). In the other case 
the patient was a young 
man twenty years of age, 
and the hydrocele and her- 
nia were both recent, and 
had formed about the same 
time. 

In encysted hydrocele of 
the spermatic cord the parts 
are generally in a condition 
favourable to a hernial de- 
scent, the cyst being most 
commonly the result of an indisposition of the 
peritoneum in the course of the cord to unite, 
or become obliterated after the arrival of the testis 
in the scrotum ; and it often happens in these 
cases that the peritoneal process above the hydro- 
cele remains patent, and in communication with 
the cavity of the abdomen. Thus at page 225, 
I have narrated two cases of encysted hydrocele 
of the cord, in which on dissection, I found an 
empty hernial sac above the cyst of the hydrocele. 
If the hydrocele extended high up, it would prevent 




HYDROCELE OF THE HERNIAL SAC. 249 

the proper adjustment of a truss, and would therefore 
require to be cured before the application of any 
instrument. 



SECTION vn. 

HYDROCELE OF THE HERNIAL SAC. 

A hernial sac sometimes becomes the seat of 
dropsical effusion, the connexion with the abdomen 
being interrupted by adhesion at the neck, or by a 
portion of adherent intestine or omentum blocking 
up the orifice. Thus the continued application of 
a truss sometimes causes obliteration of the neck of 
the sac, and the radical cure of the hernia ; but the 
lower part, remaining patent, is liable to become the 
seat of an effusion of serum. A man was admitted 
into the Hospital of La Charite in Paris, under 
Boyer, with a tumour in the right groin, which 
was found to be hydrocele of an old hernial sac. 
The hernia had been cured by the obliteration of 
the neck of the sac, and the serous pouch had re- 
mained for a time wrinkled up in the course of the 
cord, but it afterwards became the seat of dropsical 
effusion.^ Mr Pott has narrated two interesting 
cases of a collection of fluid in the sac of a conge- 
nital hernia.t In one the opening of the sac was 
closed by adherent 'omentum ; in the other it was 
blocked up by intestine. The first was the case of 

* La Lancette Frangaise, Fevrier, 1837. 

■\ Lib. cit p, 463, Cases XXXIV. and XXXV. 

32 



250 HYDROCELE OF THE HERINIAL SAC. 

a man aet. 25, who had a large scrotal swelling, 
accompanied with a remarkable fulness of the sper- 
matic process. He had had a rupture, and worn a 
truss for many years ; upon taking his truss oif, 
his rupture always came down immediately, and 
was very easily returned. After leaving his truss 
off, and substituting in its place a bandage, which 
was buckled on very tight, his scrotum gradually 
became larger, with considerable pain and uneasi- 
ness. Pott made no doubt that the tumour con- 
tained a considerable quantity of fluid, but hesitated 
respecting the disease being a hydrocele. He made 
a puncture, and let out about a pint of brown serum. 
This discharge removed the swelling from below ; 
but made little or no alteration in the upper part 
of the process. He endeavoured to reduce it ; but 
found it impracticable, and desisted, advising the 
man to wear no bandage ; and if it became trouble- 
some desired that he might see it. In about a year 
the fluid had collected ao^ain. Mr. Pott then made 
an incision from the middle of the scrotum quite 
up to the groin. The true nature of the case was 
now discovered. He found in the lower part of the 
bag, which contained the fluid, the testicle \ and in 
the upper part or neck of the same bag a consider- 
able portion of omentum, the upper part of which 
was hardened in texture, and so perfectly adherent 
to every point of the neck of the sac as to prohibit 
the return of even a fluid from thence into the 
belly : but the lower part was in its natural state, 
loose, soft, and capable of being expanded. All the 
loose part he cut ofl'; the upper part he left as he 



HYDROCELE OF THE HERNIAL SAC. 251 

found it, filled the wound lightly with lint, and 
treated the case as for the radical cure of a hydro- 
cele. In about seven weeks the man got well. 
The other was the case of a man aged twenty-two, 
who had long been subject to a rupture which never 
came lower than his groin. When a child he had 
worn a truss, but had for some years disused it. 
For a month or two past his rupture had been 
constantly down, and he had not been able to re- 
turn it. For three days symptoms of strangulation 
had existed. There was a large scrotal swelling, 
which bore very much the appearance of a hydro- 
cele ; but the upper part or spermatic process was 
hard and painful, and seemed to be girt tight by 
the tendon of the abdominal muscle. Mr. Pott 
divided the integuments, as in the operation for 
hernia, and on opening the sac let out about half 
a pint of clear limpid water, upon the discharge of 
which the whole tumour of the scrotum subsided, 
and it was supposed that he had mistaken a hydro- 
cele for a hernia. But the tumour and hardness 
about the abdominal ring still remained unaltered, 
and on passing the finger upwards a small portion 
of intestine was found engaged in the abdominal 
ring, and bound extremely tight. The stricture 
was divided ; but the gut could not be returned, 
until an adhesion which connected it to the lower 
border of the opening was discovered and also di- 
vided. The patient recovered. 

Pelletan has recorded two cases of hydrocele of 
the hernial sac (one of them congenital), in which 
the communication with the abdomen was closed 



252 HYDROCELE OF THE HERNIAL SAC. 

by adherent omentum. Though the diagnosis was 
satisfactorily established, he very properly pro- 
ceeded with much caution in the operation, and 
instead of puncturing the tumour cut carefully down, 
as in the operation for strangulated hernia. In both 
cases the hydrocele was cured by the ordinary ope- 
ration of incision.* A true hydrocele of the hernial 
sac is certainly a rai*e affection; and since niy con- 
nexion with the London Hospital I have witnessed 
only one case of it. The hydrocele was double ; the 
tumours were very large on each side, quite uncon- 
nected with the testes, and resulted from the con- 
stant wearing of a double truss for a period of 
thirty-five years. Le Dran has recorded a remark- 
able case of triple hydrocele on the same side, a 
hydrocele of a hernial sac having been combined 
with a hydrocele of the cord and with a simple 
hydrocele, which together formed a tumour the size 
of a small melon. The hydrocele of the hernial 
sac was consequent upon the radical cure of a 
hernia, the obliteration of the neck of the sac having 
been caused by the pressure of a truss.f 

Diagnosis. — In hydrocele of the hernial sac, 
the absence of a defined margin at the upper part 
of the tumour, together with the swelling at the 
abdominal ring and the inability of feeling the 
spermatic cord, being also marks of scrotal hernia, 
tend to render the diagnosis of this rare form of 
hydrocele somewhat obscure. But the detection of 



* Cliiiique Chirurgicale, torn. iii. pp. 22, 108. 

f Observations on Surgery, tr., Case I^XXV. p. 260. 



HYDROCELE OF THE HERNIAL SAC. 253 

fluid by the transparency and evident fluctuation 
of the tumour, and a careful attention to the history 
of the case, are sufficient to enable the practitioner 
to avoid any serious error. There is generally, 
also, an absence of any impulse on coughing; though 
sometimes, in consequence of the swelling extend- 
ing up into the inguinal canal, an impulse is com- 
municated to it from the abdomen, which increases 
the difficulty of the diagnosis. The extension of 
the swelling to the abdominal ring, and the testis 
being distinct from the tumour at the bottom of the 
scrotum, are sufficient to distinguish hydrocele of 
the hernial sac from simple hydrocele. I conceive 
that some little difficulty might be experienced in 
diagnosing a small hydrocele of the hernial sac from 
an encysted hydrocele of the cord high up. They 
are both distinct from the testis, and their relative 
situation and even mode of formation are very 
similar ; the only essential difference being that the 
process of peritoneum constituting the former had 
once contained either intestine or omentum. A 
hydrocele of the hernial sac occurring somewhat late 
in life, is usually of some considerable size, and its 
fluid contents are of an amber or dark colour ; whilst 
an encysted hydrocele of the cord generally appears 
before puberty, is rather small in size, and contains 
fluid which is generally colourless and nearly free 
from albumen. Attention, therefore, to these dis- 
tinguishing m^arks, and to the history of the case, 
would leave but little room for doubt. 

Treatment, — Cases of hydrocele of the hernial 
sac arising after the radical cure of a rupture, the 



254 HYDROCELE OF THE HERNIAL SAC. 

neck of the sac being permanently obliterated by 
adhesion, should be treated on the same principles 
and in the same manner as simple hydrocele. In 
the treatment of cases where there is reason to 
believe that the opening of coQimunication has be- 
come closed by the adhesion of a portion of omentum 
or intestine, more care is required, and the surgeon 
should be content with palliative means. When 
symptoms of strangulation arise, as in Mr. Pott's 
second case, the removal of the hydrocele becomes 
a matter quite of secondary importance. Scarpa 
well remarks, " Whatever difficulty these compli- 
cations may oppose to the exact diagnosis of redu- 
cible intestinal scrotal hernia, they do not occasion 
any with regard to the operation, whenever the 
hernia is affected with strangulation ; as the symp- 
toms accompanying the incarceration of the intes- 
tine show clearly the nature of the principal disease, 
and render the operation necessary, by means of 
which we have at the same time the advantage of 
laying bare what formed the complication of the 
hernia, and of curing radically both diseases."^ He 
has related an example of hydrocele of the hernial 
sac, complicated with intestinal scrotal hernia, 
which illustrates the difficulty of the diagnosis in 
these cases. A man twenty-five years of age, stout 
and very fat, was affected with incarcerated scrotal 
hernia of enormous size. The hernia was of eight 
years' standing. The day before the incarcera- 
tion, being obliged to make a rapid journey on 

"^ Treatise on Hernia, tr. by Wishart, p. 230. 



HYDROCELE OF THE HERNIAL SAC. 255 

horseback, his truss broke on the way, and on 
alighting he found the scrotum of extraordinary 
size ; he was likewise affected with nausea, acute 
pain in the groin, and inclination to vomit. The 
tumour was fully sixteen inches in circumference, 
and almost entirely concealed the penis ; it was 
broad at the bottom, narrow at the upper part 
towards the ring, equal and smooth in almost its 
whole surface, and elastic. It resembled a large 
hydrocele, and might have been taken for one, if 
there had not been evident marks of incarcerated 
intestine. Scarpa remarks, " I could with difficulty 
persuade myself that this large tumour was formed 
for the most part by water collected in the vaginal 
coat of the testicle, or in the hernial sac, as the 
patient never had the smallest mark of serous effu- 
sion in the scrotum, as well as because, from the 
repeated assertion of the patient, the hernia in the 
course of eight years had never exceeded the size of 
a hen's egg, and there was no reason to suppose 
that so much water had descended from the cavity 
of the abdomen into the scrotum in a young man 
in other respects very healthy and strong. I rather 
suspected, considering the fatness of the patient, 
that by the exertion of the riding a great mass of 
omentum had descended, although there still re- 
mained some doubt how, in so short a time, the 
hernial sac could have yielded to so great a disten- 
sion, and because the tumour had rather the appear- 
ance and elasticity of a large hydrocele than of a 
large hernia composed of intestine and omentum." 
There was no doubt as to the impossibility of redu- 



256 HYDROCELE OF THE HERNIAL SAC. 

cing the parts without an operation, as the symp- 
toms of strangulation increased in violence every 
minute. On the first cut into the hernial sac, about 
three pounds of yellowish serum were discharged. 
It was a common scrotal hernia. At the upper part 
of the sac there was a loop of small intestine about 
two inches long, but no omentum. The stricture 
was divided, and the intestine returned. The 
patient recovered, the wound having healed in 
seven weeks. 

The term hydrocele of the hernial sac should, I 
think, be restricted to cases of a chronic collection 
of fluid in the sac of an old hernia, in which the 
communication with the abdomen has been perma- 
nently obliterated by adhesion at the neck, either 
of the sides of the sac, or of a portion of omentum 
or intestine. The above case was clearly not of 
this description. It was an instance of strangulated 
scrotal hernia attended with a remarkable effusion 
of fluid, which may be denominated a spurious hy- 
drocele of the hernial sac ; a term that would apply 
to all cases of a hernial descent coupled with serous 
effusion, whether the communication with the ab- 
domen be closed or open, and the fluid reducible 
into the abdomen. A somewhat similar case of 
large strangulated scrotal hernia, in which the bulk 
of the tumour was formed by serous effusion, is 
recorded by Mr. Shaw of the Middlesex Hospital.^ 
Nothing is more common than the presence of fluid 
in the sac of a strangulated hernia, though it rarely 

* Lond. Med. and Phys. Journal, vol. Ivi. p. 18. 



HYDROCELE OF THE HERNIAL SAC. 257 

exists, as in these cases, in such abundance as to 
cause any difficulty in the diagnosis. I have met 
with three cases of. strangulated scrotal hernia, in 
which several ounces of fluid were contained in the 
same sac with the protruded viscera, and in which 
the rupture being congenital no testicle could be 
distinguished ; but the previous history, fulness at 
the abdominal ring, and well-marked symptoms of 
strangulation, were sufficient to indicate the true 
nature of the complaint. In one of these cases, 
which was operated on by Mr. Hamilton, the stric- 
ture was divided external to the sac ; and the fluid 
which had concealed the intestine, adherent omen- 
tum, and testis, remained after the operation, but 
became absorbed as the patient recovered. Had 
Scarpa, in the case related above, examined the tu- 
mour by transmitted light, he could scarcely have 
suspected that the bulk of the swelling consisted of 
omentum. In those cases of spurious hydrocele of 
the hernial sac in which the fluid and intestine or 
omentum are reducible, the complication may be 
made out by returning the contents of the sac into 
the abdomen, the patient being in the horizontal 
posture ; when, by pressing the finger gently on the 
abdominal ring and allowing the patient to rise, the 
fluid will slip down into the scrotum, and produce 
a transparent tumour or hydrocele. On entirely 
remitting the pressure, the intestine or omentum 
will be felt descending into its former situation. In 
the following case, which was shown me by Mr. 
Adams, the symptoms produced by spurious hydro- 
cele of the sac of a congenital hernia closely re- 



258 HYDROCELE OF THE HERNIAL SAC. 

sembled those of a congenital hydrocele. — A lad, 
aged twelve, applied as an out-patient at the London 
Hospital, on account of a swelling which occupied 
the left side of the scrotum. It was a transparent 
tumour, of an oval form, reaching upwards into 
the abdominal canal, which fluctuated, completely 
filled the scrotum, and received an impulse on 
coughing. The left testis was imperceptible. On 
making gentle pressure the swelling disappeared 
rather suddenly, and then the testis could be readily 
distinguished, and was found less than half the size 
of the gland on the right side. The sac which con- 
tained the fluid felt a good deal thickened. The 
boy stated that the swelling had existed since he 
was two years of age. This appeared to be a case 
of congenital hydrocele, of which, indeed", it pre- 
sented all the usual symptoms, except that on pres- 
sure the swelling disappeared suddenly instead of 
gradually. The boy was accordingly directed to 
have a truss to press on the abdominal ring. After 
it had been worn for three wrecks, the fluid was 
found to have entirely disappeared from the sac, 
and none descended on the removal of the truss. 
When, however, the boy coughed, a small intestinal 
hernia came down. It then became clear that this 
had been a case of spurious hydrocele of the hernial 
sac ; and thus was explained the only symptom un- 
usual in congenital hydrocele, viz. the sudden dis- 
appearance of the tumour on pressure, the fluid 
passing into the abdomen together with the intes- 
tine, which it had completely masked from observ- 
ation. 



HYDROCELE OF THE HERNIAL SAC. 259 

M. J. Cloqiiet has detailed the particulars of the 
dissection of the parts, in a case of congenital in- 
guinal hernia on the right side, found in the body 
of a man aged thirty affected with ascites, who 
had worn a truss. The testicle, which had not 
descended lower than just outside the abdominal 
ring, had formed a valve, which admitted the passage 
of fluid into the sac, but prevented its return into 
the abdomen.* The testis, in this case, seems to 
have acted much in the same way as the valvular 
'fold of peritoneum which exists at the ring in 
many quadrupeds. 

In operating for the removal of fluid in cases in 
which there is reason to suspect that intestine or 
omentum is also contained in the hernial sac, the 
surgeon should proceed in the most cautious 
manner. Monro, senior, relates the following case.t 
— " An old man had long laboured under a hernia, 
which had not been reduced for many years. The 
tumour became at last of a monstrous size, de- 
scending nearly to his knee, and having a propor- 
tional transverse diameter ; he was confined to lie 
on his back, had violent pain both in the tumour 
and his loins, and his flesh and strength wasted. 
In some places a plain fluctuation was perceived, 
without any of the unequal solid substances felt 
every where else. Neither the water nor solid sub- 
stances could be pushed into the belly. The 



* Recherches sur les Causes et I'Anatomie des Hernies Abdomi- 
nal es, p. 97. 

t Medical Essays and Observations, vol. v. p. 314. 



260 HYDROCELE IN THE FEMALE. 

tumour being pressed, so as to make one of those 
parts where the fluctuation was most evident and 
the teguments were thinnest as tense and pro- 
minent as possible, a trocar, as small as a crow- 
quill, was thrust very slowly through the teguments 
and cyst. Whenever the bag was pierced the stilet 
was taken out, and the canula was pressed a little 
forward, through which six pounds of clear serous 
water ran out ; then the convolutions of the in- 
testines and the knotty parts of the omentum were 
plainly felt, but none of them would reduce." The 
patient was greatly relieved of his pain, and no 
further operation was thought proper. Unless the 
fluid should accumulate in so large a quantity as to 
cause serious inconvenience to the patient, as in 
this remarkable case, an operation for its removal 
would not be proper ; for the surgeon is not war- 
ranted in opening a serous sac containing intestine 
on slight grounds. If it became necessary to get 
rid of the fluid, I should think acupuncture would 
be the plan best suitable to such a case. If the 
intestine or omentum were reducible, the applica- 
tion of a truss would be the treatment required. 

SECTION vin. 

HYDROCELE IN THE FEMALE. 

Tumours analogous to hydrocele occasionally 
occur in the female, in connexion with the round 
ligament of the uterus, at its termination in the 
groin and pudendum. Three varieties of this af- 
fection may be distinguished. 



HYDROCELE IN THE FEMALE. 261 

1 . Diffused hydrocele of the round ligament, which 
is simply an oedema of the cellular tissue of the 
part corresponding to the diffused hydrocele of the 
spermatic cord. It is an affection of no moment, 
and needs no particular description. 

2. Hydrocele of the Canal of Nuck. — A diverti- 
culum or pouch of peritoneum may commonly be 
observed in the foetus, prolonged through the ab- 
dominal ring w^ith the round ligament of the uterus. 
This pouch, which was first noticed by Nuck,* 
and has been named after him, often remains un- 
obliterated during life. When examined in the 
adult it usually consists of a serous pouch, about 
half an inch in length, external to the abdominal 
ring, which communicates with the cavity of the 
abdomen by an aperture so contracted as scarcely 
to be capable of admitting the passage of a probe. 
This little pouch may become the seat of dropsical 
effusion, and form a fluctuating cystic tumour, the 
contents of which are reducible into the abdomen, 
thus corresponding to the congenital hydrocele in 
man. The only treatment required for this affec- 
tion is the application of a truss to obtain the 
obliteration of the sac, after which the fluid usually 
disappears. 

3. Encysted hydrocele of the round ligament is 
produced by the obliteration of the neck of the 
peritoneal pouch, the lower part remaining patent, 
and being distended with serum. The cyst is situ- 

"^Adenographia Curiosa. 



262 HEMATOCELE OF THE TESTIS. 

ated in front of the round ligament, either in the 
inguinal canal or immediately below the abdominal 
ring ; and it occasions a tense fluctuating tumour, 
which sometimes acquires the size of a hen's egg. 
It may be mistaken for a hernia, from which it can 
be distinguished by applying the same rules as 
those given for the diagnosis of an encysted hy- 
drocele of the spermatic cord. It is to be treated 
also on the same principles as those applicable to 
that affection. As in hydrocele of the cord high 
up, the proximity of the peritoneum must be borne 
in mind by the surgeon, if he has recourse to active 
means for obliteration of the cyst. 



CHAPTER V. 

HEMATOCELE. 






Hematocele is a term applied to the swelling 
occasioned by effusion of blood in the sac of the 
tunica vaginalis, or in the substance of or cyst in 
the spermatic cord. 



SECTION L 



HEMATOCELE OF THE TESTIS. 



In haematocele of the tunica vaginalis, which is 
by far the most common seat of sanguineous effu- 
sion, the extravasation may take place in a healthy 
state of the parts, or it may succeed or be combined 



HEMATOCELE OF THE TESTIS. 263 

with hydrocele. The first form occurs from the 
accidental rupture of some blood-vessel into the 
vaginal sac. It is usually produced by a blow. 
Thus it is liable to happen to a person on horse- 
back, from the testicle being struck against the 
pommel of the saddle ; or may be occasioned by 
violent efforts made in straining, as in the attempt 
to raise a heavy weight : sometimes the effusion 
takes place without any apparent cause. In these 
cases the testis immediately enlarges, sometimes to 
more than double its natural size, from the sudden 
distension of the tunica vaginalis with blood. 

The second form of hogmatocele, in which the 
extravasation takes place in combination with 
hydrocele, is of more frequent occurrence than 
the first. It may be produced by a blow, or by 
the wound of some vessel in the operation of tap- 
ping. The testis, owing to its free mobility, does 
not often suffer from mechanical violence ; but 
when hydrocele exists a tumour is formed, which, 
from its prominence and size, is necessarily more 
exposed to injury. A blow occasions a rupture 
into the tunica vaginalis of some of the enlarged 
vessels ramifying outside the sac, and the blood 
which is extravasated, mixing with the fluid of the 
hydrocele, produces a sudden increase in the size 
of the tumour. The quantity of blood effused under 
these circumstances varies considerably. It may 
be merely sufficient to impart a red tinge to the 
serum. In general, however, it is greater ; and it 
sometimes exceeds the serum in amount, occasion- 
ing a rapid enlargement of the swelling to more 



264 HEMATOCELE OF THE TESTIS. 

than double its previous volume. A h^ematocele 
may be produced in the operation of tapping a 
hydrocele in two ways. 1. It may be occasioned 
by the accidental wound of some vessel ramifying 
over the tunica vaginalis, which, instead of bleeding 
externally, or into the celkdar tissue of the scrotum, 
pours its blood into the sac of the hydrocele. This 
accident sometimes occurs when the operation is 
performed with a trocar, but it is more liable to 
happen w^hen the lancet is used. 2. A hasmatocele 
may be caused by the trocar or lancet penetrating 
too far, and wounding the testis or spermatic artery. 
A case in which a hoeraatocele was occasioned by 
a wound of the artery in this operation is recorded 
by Scarpa.^ 

In hoematoceles consequent upon injury, few 
opportunities are afforded of tracing the source of 
haemorrhage. When the parts are in a healthy 
state, the bleeding probably proceeds from the ves- 
sels ramifying between the tunica albuginea and 
the tunica vaginalis testis, in consequence of the 
rupture of the latter delicate membrane. Sir B. 
Brodie remarks, that a rupture of a vessel producing 
hcematocele may arise from a diseased condition of 
the arteries, analogous to that which occurs in the 
brain under the form of sanguineous apoplexy, in 
old persons whose arteries are ossified.t In haema- 
tocele combined with hydrocele, and caused by a 
blow, the tunica vaginalis is ruptured, and the blood 



* Treatise on Hernia, tr. by Wishart, p. 76. 
f London Medical Gazette, voL ix. p, 927. 



HEMATOCELE OF THE TESTIS. 265 

is derived from some vessel distributed on its ex- 
ternal or adherent surface. In the case of g. man 
who had long had a hydrocele, and had received a 
severe blow upon it^ which suddenly increased the 
swelling, bruised the scrotum, and produced great 
pain from distension. Sir A. Cooper, on making an 
incision into it and discharging a large quantity of 
water and coagulated blood, found a rent in the 
tunica vaginalis between one and two inches in 
length covered with coagulum.'^ In general, when 
the blood effused is of small amount, it becomes 
dissolved in the fluid of the hydrocele, which is 
tinged of a red colour. If a larger quantity be 
extravasated, coagula are formed, and these remain 
undissolved in the fluid. In hsematoceles which 
have existed for a long period, the blood becomes 
changed into a substance resembling coffee grounds, 
of a brownish-red or chocolate colour, and more or 
less fluid. The coagula sometimes present a cellu- 
lar or honeycomb appearance, the cells being filled 
with a reddish serum. Occasionally the blood is 
found converted into a solid fibrinous substance, of 
a yellow or fawn colour, arranged in firm layers, 
similar to the coagula lining the sac of an aneurism. 
In many instances the effused blood is felt as a 
foreign body, and produces inflammation in the 
tunica vaginalis, which becomes coated with lymph. 
Under these circumstances, the tumour undergoes 
a further increase ; and the lymph efilised becoming 
mixed with the blood and serum, modifies the ap- 



* Lib. cit. p. 212. 
34 



266 H.^MATOCELE OF THE TESTIS. 

pearance of the contents of the cyst, which is ren- 
dered soft, turbid, and of a light colour. Some- 
times the inflammation goes on to suppuration, in 
which case pus is also found in the sac. The in- 
flammation usually extends from the tunica vagi- 
nalis to the cellular tissue and fascia external to 
the sac, which in recent cases are found infiltrated 
with serum and lymph, and in cases of old standing 
become greatly thickened, indurated, and com- 
pacted. In a case of hoematocele occasioned by 
the wound of a vessel in tapping a hydrocele, in 
which I was consulted, the inflammation which 
ensued caused in the course of a fortnight great 
thickening of the tissues external to the sac, and 
the form^ation of an abscess in the scrotum on one 
side of the hcematocele. 1 have found the tunica 
vaginalis and tissues investing it as much as half 
an inch in thickness, and very firm and dense. 
These changes in the sac are produced by a more 
chronic form of inflammation of the fascia and 
cellular tissue investing the sac. In these old 
cases, the internal surface of the tunica vaginalis, 
instead of presenting its natural smooth and polished 
surface, is rough, granular, and irregular, and feels 
as dense and tough as a piece of leather, having 
lost all the characters of a serous membrane. 

In hcematocele the testis preserves the same re- 
lation to the remainder of the tumour as in simple 
hydrocele, being situated at the posterior part, and 
rather below the centre. Its position, however, is 
liable to similar alterations as occur in hydrocele, 
and they are dependent upon the same causes. I 



HiEMATOCELE OF THE TESTIS. 267 

once witnessed an '' untoward event," which hap- 
pened in the practice of a surgeon who was un- 
aware of the testis being out of its usual position. 
A young man had a hydrocele, which had suc- 
ceeded to an attack of secondary orchitis, occasion- 
ing an adhesion of the gland to the front of the sac 
at its lower part. The case became converted into 
a haematocele by the wound of a vessel in the ope- 
ration of tapping. Inflammation ensued, and it 
became necessary to lay open the sac. The sur- 
geon, in carrying the incision to the lower part of 
the tunica vaginalis, divided the vas deferens, and 
severed the sound testicle nearly in two with his 
bistoury, the thickening around the sac having pre- 
vented him from detecting the gland in its unusual 
situation. 

In hcematocele the glandular structure of the 
testis sometimes disappears in the same manner as 
in old cases of hydrocele, atrophy being occasioned 
by the long-continued pressure arising from the 
extravasated blood. On examining the body of an 
elderly negro who died in St. George's Hospital of 
disease in the lungs. Sir B. Brodie observed on the 
right side of the scrotum a large tumour, which 
was formed by the tunica vaginalis, distended with 
about twelve ounces of fluid having the appearance 
of coffee-grounds, with numerous masses of solid 
substance, manifestly fragments of coagulum, float- 
ing in it. The tunica vaginalis itself was much 
thickened. The substance of the testicle, the tunica 
albuginea, and the tunica vaginalis immediately 
covering it, were entirely destroyed, so that not a 



268 



HiEMATOCELE OF THE TESTIS. 



vestige of these parts could be discovered. The 
vas deferens adhered to the posterior part of the 
tumour, and was imperceptibly lost at the part 
where it usually joins the testicle. Sir B. Brodie 
likewise met with another case in which the appear- 




ances on dissection were precisely similar •, but here 
also he unfortunately lost an opportunity of learn- 
ing the history of the case during the patient's life- 
time."^ In the examination of a large haematocele 
which had existed for njany years, and was removed 
by operation under the impression that it was a 
solid enlargement of the testis, 1 found the tunica 



* Lond. Med. and Phys. Journal, vol. Iviii. p. 299. 



HEMATOCELE OF THE TESTIS. 269 

vaginalis nearly half an inch thick, and full of a 
soft friable substance of a chocolate colour ; the 
testis, which was situated at the posterior part of the 
cavity, was somewhat flattened, and partly imbedded 
in the thickened cyst ; but the glandular structure 
was perfectly healthy, and the bulk of the organ 
scarcely less than natural. The hsematocele, with 
the sac and testis laid open, is represented in the 
opposite engraving. The structure of the testis 
is indeed usually sound in hcematocele, but its 
nutrition becomes impaired when the disease is 
of very old standing. 

Symptoms. — The first form of haematocele ap- 
pears suddenly after a strain or the receipt of some 
injury. The testis quickly enlarges to more than 
double its natural size, and forms a tumour, which 
is of an oval shape, tender, tense, and fluctuates 
indistinctly. If the haematocele be occasioned by a 
blow, this enlargement is accompanied with appear- 
ances of extravasation in the cellular tissue of the 
scrotum. Slight pain and tenderness continue for 
some days, and then subside, leaving the swelling 
but little altered, except that it feels rather more 
solid than at first. 

In the second form, in which a hydrocele becomes 
converted into a hsematocele, the tumour undergoes 
a sudden increase in size, and becomes more or less 
painful. It still preserves its pyriform shape and 
even, uniform surface ; but it feels very tense, and 
heavier and more solid than before, and fluctuates 
very indistinctly. In the course of a few hours, or 
on the following day, inflammation arises, the part 



270 HJE.MATOCELE OF THE TESTIS. 



1 



feels hot and tender, the scrotum becomes tense 
and sometimes injected, and further enlargement 
ensues. These symptoms are attended with general 
febrile disturbance. Occasionally there is exces- 
sive pain, and high symptomatic fever ; and the 
inflammation, if allowed to proceed, goes on to 
suppuration. In other cases the tumour from the 
first assumes an indolent character, becomes more 
firm and solid, and feels heavier than before, but 
undergoes no alteration in size. It may remain 
stationary in this condition for many years, pro- 
ducing no inconvenience beyond that which arises 
from its bulk and weight. 

Diagnosis. — A haematocele may be distinguished 
from a hydrocele by the absence of transparency, 
the obscure character of the fluctuation, the heavy 
feel of the tumour w^hen balanced in the hand, and 
the sudden and accidental mode of its occurrence. 
In old cases, in which the tunica vaginalis and its 
envelopes have become much thickened and in- 
durated, the tumour possesses so firm a character, 
feels so heavy and solid, that it is very liable to be 
mistaken for a chronic enlargement of the testis ; 
and the diagnosis, at all times difficult, in some 
instances cannot be satisfactorily made out by the 
nicest manipulation of the most experienced hands. 
The records of surgery furnish many cases in which 
castration has been performed from a mistaken 
diagnosis : I have known three instances of the 
kind myself In chronic enlargement of the testis, 
whether from malignant deposit or other disease, 
the gland loses for the most part its natural sensi- 



HEMATOCELE OF THE TESTIS. 271 

bility ; but in haematocele pressure on the back 
part, where the testis is usually situated, occasions 
the peculiar pain always experienced when the 
organ is compressed. When the least doubt exists, 
it should in all cases be removed by the introduc- 
tion of a lancet or trocar before any further ope- 
ration is undertaken. Swelling of the scrotum from 
extravasation of blood in its loose cellular tissue 
may arise somewhat suddenly after a blow ; but 
the diffused nature of the tumour and its extension 
to both sides of the scrotum, the concealment more 
or less of both testes, doughy feel, and red colour 
of the skin, are characters too clearly expressive of 
the nature of the case to mislead the practitioner. 
Treatment, — In the first form of haematocele, if 
the quantity of blood effused into the tunica vagi- 
nalis be small, the treatment should be simply 
antiphlogistic. The patient is to be kept in the 
recumbent position, with the testis supported ; a 
cold lotion is to be applied to the part, and the 
bowels must be gently acted upon. If the tender- 
ness be considerable, or symptoms of inflammation 
arise, a few leeches should be applied to the scro- 
tum, or, if there be much contusion of the part, to 
the corresponding groin. By such means, inflam- 
mation may be prevented, and in the course of 
time the effused blood becomes absorbed. In gene- 
ral, this takes place very gradually and slowly, and 
it is often many months before the blood is entirely 
removed. If the quantity of blood extravasated be 
large, so as to cause great tension of the tunica 
vaginalis and severe pain, and endanger the nu- 



272 HiEMATOCELE OF THE TESTIS. 

trition of the testis, it becomes necessary to lay 
open the sac by a straight incision, and to remove 
the blood. Means must afterwards be taken to 
subdue the inflammation which ensues, and the 
part then heals by granulation. 

When hagmatocele is combined with hydrocele, 
the usual practice is at once to make an incision 
into the tunica vaginalis, and discharge its contents, 
leaving the cure to be effected afterwards by the 
process of inflammation. Sir B. Brodie observes, 
" If on drawing off the contents of the sac I find 
that the fluid is tinged with blood, I allow the fluid 
again to collect, and repeat this operation at cer- 
tain intervals until it is voided perfectly clear. You 
may then perform the common operation for hy- 
drocele by injection and with success."^ I have 
adopted this proceeding in two cases, in which the 
blood eflfused was small in quantity, and found it 
obviate the necessity for a severer operation. 

If much inflammation arise, the tunica vaginalis 
ought to be laid open without delay, and the source 
of irritation removed. No advantage is gained by 
deferring a proceeding which must subsequently be 
resorted to ; whilst, on the contrary, if the operation 
be delayed, it is rendered more painful and severe 
by the parts becoming thickened and enlarged. 
When, too, the quantity ,of extravasated blood is 
large, it is hopeless to await its absorption ; it 
should be removed at once by an incision. The 
tunica vaginalis may be punctured with a lancet at 

* Medical Gazette, vol. ix. p. 928. 



HEMATOCELE OF THE TESTIS. 273 

its upper part, a director or the finger introduced, 
and the whole extent of the membrane then laid 
open by an incision with a bistoury carried quite to 
its lower part, in order to prevent any bagging of 
the discharge afterwards. This must be done with 
care, so as to avoid wounding the testis. 

If in a recent case the spermatic artery or a ves- 
sel of any size has been wounded, and continues to 
bleed, it can then be easily secured. In the case 
related by Scarpa, previously alluded to, the 
wounded spermatic artery was found, after the 
tunica vaginalis had been laid open, pumping out 
blood. The removal of the pressure occasioned by 
the extravasated blood will be favourable to the 
recurrence of the hosmorrhage. In dressing the 
wound, the surgeon may leave a piece of lint be- 
tween the edges to prevent union by the first in- 
tention ; but it should not be carried to the bottom 
of the sac, or be placed in contact with the serous 
membrane. Severe symptoms and a good deal of 
constitutional irritation frequently follow this ope- 
ration : they are occasioned by acute inflammation 
of the exposed sac, which being much enlarged and 
dilated in this disease affords a considerable extent 
of surface. In a few hours the skin becomes hot ; 
the pulse full, frequent, and bounding; the face 
flushed ; the tongue white and furred, and the part 
hot and painfuL The patient becomes restless, and 
sometimes delirious. By antiphlogistic treatment 
these symptoms may soon be moderated, and in a 
few days entirely removed. Their severity depends 
in a great measure upon the age and natural con- 

35 



274 HiEMATOCELE OF THE TESTIS* 

stitution of the patient, as well as upon his state of 
health at the time of the operation. In old persons 
gangrene has arisen from the incision of a haemato- 
cele ; and formerly, when it was the practice to stuff 
the bottom of the wound with lint or other extra- 
neous substances for the purpose of insuring suffi- 
cient inflammation, the operation was not altogether 
free from risk^ especially in persons of an unhealthy 
constitution. The danger consists in exciting too 
much inflammatory action, and the object of the 
after-treatment is to moderate that which is almost 
certain to follow from the nature of the parts ex- 
posed in the operation. I have noticed, however, 
that the inflammation and febrile disturbance are 
less severe after the incision of old-standing haema- 
toceles, in which the sac is much consolidated, and 
its contents are thick and grumous, than in more 
recent cases of the disease. In these old cases, the 
tunica vaginalis having pretty well lost the charac- 
ters of a serous membrane, the inflammatory action 
which arises in it is less active, granulations soon 
form, and in general the wound heals readily. 
Castration is very rarely required for this disease. 
It has been recommended in preference to incision 
in cases of consolidated haematocele in old people ; 
but the former is a much more severe operation 
than the latter, and would only be necessary in 
cases of ossific deposit in the sac. 



H.^MATOCELE OF THE SPERMATIC CORD. 275 

SECTION II. 

HJEMATOCELE OF THE SPERMATIC CORD» 

This affection, which was first noticed by Mr. 
Pott, is generally produced by the accidental rup- 
ture of a spermatic vein during violent and sudden 
exertion, as in straining to lift a heavy weight, 
when blood immediately escapes into and infiltrates 
the loose cellular tissue along the cord, where it 
accumulates, its further diffusion being prevented 
by the fascious envelope of this part. Mr. Pott 
has related three cases, all of which occurred in 
this way. It may happen to persons in good 
health, and whose genital organs are free from 
disease ; but it is a complaint of rare occurrence. 
In contusions of these parts, blood is often effused 
amongst the structures of the cord, as well as in 
the cellular tissue of the scrotum ; but the symp- 
toms of the two are so combined, that it is impos- 
sible to make any distinction in practice, and they 
must be viewed and treated as common cases of 
ecchymosis. 

An encysted hydrocele of the spermatic cord 
may become converted into a haematocele. In the 
pathological museum of St. Bartholomew's Hospi- 
tal,^ there is a preparation of encysted haematocele 
of the spermatic cord. The cyst is empty ; but it 
is described to have contained blood, and its walls 
are deeply stained with the colour of partially de- 

* Series 22d, No, 11, in printed Catalogue. 



276 



HiEMATOCELE OF THE SPERMATIC CORD. 



composed blood. Its lining membrane is wrinkled 
and coarsely granular ; and 
the tissues around it are thick- 
ened, brawny, and adherent 
together. I lately examined 
a preparation in the Hunte- 
rian Collection, which I have 
no doubt is a specimen of old 
encysted hoematocele of the 
spermatic cord. (See figure.) 
There is a good-sized cyst, 
lined by a membrane, polished 
and a little wrinkled, filled 
with a soft tawny-looking gra- 
nular matter (3), resembling 
the altered coagulum of blood 
which I have observed in or- 
dinary hsematocele after long 
maceration in spirit. The 
tissues around the cyst are 
thickened and indurated, just like those around 
an old haematocele of the testis. There is a hernial 
sac^ immediately above it (2), and a hydrocele 
below, with the sac open for some distance up the 
cord as far as the cyst of the haematocele, which does 
not communicate either with the tunica vaginalis or 
the hernial sac. I am unacquainted with any case in 
which such a change has been detected during life ; 
but I should expect that it would be attended with 




* In the preparation the hernial sac is laid open behind, instead of 
in front, as represented in the figure, in order to bring it into view. 



HiEMATOCELE OF THE SPERMATIC CORD. 277 

pain and sudden enlargement of the swelling, which 
would lose its transparency, fluctuate \e&s distinctly, 
and feel more firm and solid than before. 

The symptoms produced by a diffused haemato- 
cele of the spermatic cord are very similar to those 
of diffused hydrocele ; from which, however, it 
may be distinguished by its sudden appearance. 
Mr. Pott relates the following case. — A labouring 
man who had fallen down with a load on his back, 
was brought into St. Bartholomew's Hospital for 
a supposed rupture, a swelling having appeared in 
the groin and scrotum immediately after the acci- 
dent. The tumour seemed to occupy the whole 
spermatic process, which was so enlarged by it 
that it was impossible to feel the passage of it from 
the abdomen through the muscle ; but the testicle 
below it was perfectly distinct. The appearance 
of a tumour, the suddenness of its formation, the 
distinct fluctuation of the testicle below, and an 
accidental circumstance of the man's not having 
had a stool for two days past, inclined Mr. Freke 
to believe it to be hernia, and to treat it accord- 
ingly. After fruitless attempts at reduction, he 
determined upon an operation. He divided the 
superficial parts and tendinous opening in the ab- 
dominal muscle, and made several trials to reduce 
what he supposed to be the gut without opening 
the sac, but ineffectually. He was at length 
obliged to lay open the containing membrane, when 
a large quantity of blood, partly fluid and partly 
grumous, burst forth, and the whole tumour sub- 
sided. The parts were washed, and search made 



278 HiEMATOCELE OF THE SPERMAT[C CORD. 



1 



for the bleeding vessel, but it could not be found. 
The wound was dressed, and the man got well."* 
In this case it does not appear that there were any 
urgent symptoms of hernia demanding an operation. 
The costive state of the bowels was an accidental 
circumstance, which might have been shortly re- 
moved by the exhibition of a purgative. An 
operation can very rarely be required in any case 
of diffused hoematocele. If left alone, the blood will 
in the course of time be removed by absorption. 
All that appears to be required in the way of treat- 
ment is to check any tendency that may arise to 
inflammation. If the tumour, however, should 
continue to increase, haemorrhage still going on 
and infiltrating the cellular tissue, it may become 
necessary to make an incision, in order to secure 
the bleeding vessel. The only case that I know of, 
in which the operation was really necessary, is 
detailed by Mr. Pott. — A young fellow straining 
at stool felt a sudden pain in his left groin ; and, 
upon examination, found a swelling extending from 
thence into the scrotum. He took it for a rupture, 
and immediately applied to an advertising opera- 
tor ; who, after unsuccessful attempts to reduce it, 
applied a truss. After some days, during which 
the pain and swelling increased, he was seen by 
Mr. Pott. The tumour was large, and had some- 
what the feel of an omental hernia ; the abdominal 
aperture seemed dilated ; the testicle was tolerably 
distinct below ; pain in the erect posture was con- 

* Lib. cit. Case XXX. p. 456. 



HEMATOCELE OF THE SPERMATIC CORD. 279 

siderable, but in a supine one very little : he had 
neither heat, quickness of pulse, hiccough, nor 
vomiting, and had been thrice at stool that day. 
Notwithstanding he was bled freely and kept in 
bed, the pain and tumour increased, and fluctuation 
became palpable. Thinking that the fluid might 
possibly be collected in the sac of an omental 
hernia, Mr. Pott made a puncture with a lancet, 
and let out some ounces of clear blood. The 
haemorrhage continuing for three or four days, an 
incision of some length was made up to the groin, 
and the cellular membrane of the spermatic process 
was found loaded with extravasated blood. The 
wound was dressed with lint pressed out from a 
styptic ; but an alarming return of the haemorrhage 
soon after induced Mr. Pott to perform castration.* 
Modern surgeons will not be inclined to admit that 
castration was " the only remedy in this case." 
Had diligent search been made for the vessel, I 
should think it mioht have been found and secured. 
An encysted haematocele of the cord would pro- 
bably require to be treated in the same way as a 
haematocele of the testis. In slight cases sufficient 
relief may be afforded by rest and antiphlogistic 
measures : if the tumour should become painful and 
inflamed, and show no disposition to disperse, the 
blood must be liberated by an incision, and the 
wound be encouraged to heal by granulations from 
the bottom of the cyst. 

* I.ib. cit. Case XXXI. p. 458. 



280 ORCHITIS. 



CHAPTER VI. 

ORCHITIS. 

InflaMxMation of the testis occurs in two forms, 
acute and chronic ; and it may commence either 
in the body or secreting part of the organ, or in 
the epididymis. Inflammation beginning in the 
body of the testis may be idiopathic, or may be ex- 
cited by external violence : the disease is at first 
confined to the interior of the organ, the epididymis 
and tunica vaginalis being affected only secondarily, 
and sometimes entirely escaping. Orchitis is far 
more frequently a consecutive affection than a pri- 
mary, the inflammation being transmitted from the 
urethra by the course of the vas deferens. In this 
latter form of orchitis, which is familiarly known 
by the term hernia humoralis, the epididymis is 
first attacked, and the tunica vaginalis generally 
participates in the disease, 

SECTION I. 

ACUTE ORCHITIS, 

Few pathologists have examined a testis in a 
state of acute inflammation, and I am unacquainted 
with any authentic account of the alterations in 
structure from inflammation originating in the body 
of the gland. I have twice been able to inspect 



ACUTE ORCHITIS. 281 

a testis affected with acute secondary orchitis ; 
and the following description of the pathological 
appearances is drawn up from these examinations, 
and from the account of the dissection of two tes- 
tes affected with gonorrha3al inflammation recorded 
by M. GaussaiL* The tunica vaginalis is more or 
less distended with lymph, or albuminous matter 
infiltrated with reddish serum, which form loose 
adhesions between the opposed surfaces of the 
membrane ; these adhesions are so slight as easily 
to admit of being broken down with the finger. 
The membrane is injected with a multitude of 
minute red vessels, which ramify in various direc- 
tions, and form a compact network. At a later 
period red vessels may be traced, proceeding from 
the free surface of the tunica vaginalis to the false 
membranes forming the adhesions. The volume 
of the testis appears very little, if at all increased, 
the great bulk of the tumour being occasioned by 
the effusion into the serous sac. When cut into, 
the gland appears somewhat darker than natural, 
from a congested state of its vessels. The epididy- 
mis, particularly the lower part, is enlarged to 
twice, and sometimes thrice its natural size, and 
feels thick, firm, and indurated. This enlargement 
is produced by the effusion of a brownish deposit 
in the cellular tissue between the convolutions of 
the duct. The coats of the vas deferens are thick- 
ened, and the vessels ramifying near them injected. 



* Memoire sur I'Orchite Blennorrhagique, Archives Generales de 
Medecine, torn, xxvii. p. 210. 

36 



282 ACUTE ORCHITIS, 

sometimes along the whole extent of the duct. Al- 
buminous deposit is found in the cellular tissue 
around the tortuous part of the vas deferens and 
tail of the epididymis, which frequently forms the 
bulk of the swelling observed in these cases. Owing 
to the epididymis being the part chiefly and most 
constantly affected in consecutive orchitis, some of 
the modern French writers have denominated the 
disease epididymitis. 

In treating of the acute inflammatory changes in 
the tunica vaginalis (page 145), I particularly re- 
marked that the inflammatory action was very liable 
to extend to the substance of the epididymis, but 
not to the body of the testis ; and I noticed the pa- 
thological law enunciated by Gendrin, by which 
this circumstance was accounted for. We find, too, 
that inflammation of the epididymis is much more 
readily propagated to the tunica vaginalis than in- 
flammation originating in the glandular structure 
of the testis. When inflammation commences in 
the body of the gland, the enlargement takes place 
slowly, and is seldom considerable until the disease 
has existed for some length of time, which is easily 
explained by the unyielding texture of the tunica 
albuginea, and the circumstance of the tunica vagi- 
nalis remaining unaffected. Suppuration occasion- 
ally takes place in this form of orchitis, whereas in 
consecutive inflammation the formation of pus in 
the substance of the gland is of rather rare occur- 
rence. I do not mean, however, to imply that the 
glandular structure of the testis never suffers in 
consecutive orchitis, for I believe that it does so in 



ACUTE ORCHITIS. 283 

some instances ; but, according to my observations, 
and I have paid some attention to the subject, it 
very commonly escapes, the inflammation not ex- 
tending further than to the epididymis. 

When inflammation terminates in suppuration, 
owing to the density, thickness, and low organiza- 
tion of the tunica albuginea, the matter is so slow 
in making its way externally, that it generafly bur- 
rows in various directions, producing numerous 
sinuses throughout the gland, and disorganizing its 
delicate structure. The matter sometimes becomes 
encysted, forming a separate abscess. In these 
cases, when the matter efiused is small in quantity, 
after all inflammation has subsided, the more fluid 
particles are absorbed, and the pus remains for a 
considerable time in the form of an indolent con- 
crete mass, which has been mistaken, after death, 
for tubercular deposit. The pus, when found in 
this concrete state, appears at first sight very like 
crude tubercular deposit ; but on further examina- 
tion, it will be found to be contained in a distinct 
cyst, from which it may easily be separated, and 
the structure of the testis will be perceived to be 
more or less altered from its healthy state ; whereas 
in tubercular disease the morbid deposit is in im- 
mediate contact with the tubular structure, which, 
though atrophied by pressure, is usually in other 
respects sound. Concrete pus may likewise be 
mistaken for the firm yellow matter effused in 
chronic inflammation. It differs from it, however, 
in being friable and easily broken up, and also 
in being enclosed in a cyst ; whereas the yellow 
fibrinous substance is homogeneous and consistent, 



284 



ACUTE ORCHITIS. 




and almost inseparably diffused amongst and con- 
nected with the convoluted tubuli around it. The 
distinctive characters just de- 
scribed will be easily recog- 
nised on comparing the ac- 
companying representation 
of concrete pus encysted in 
the testis from a preparation 
in the collection of the late 
Sir A. Cooper, with the figures 
at pages 315 and 349. I 
examined two enlarged testes 
taken from a man who died 
somewhat unexpectedly from 
a disease of the larynx. Both 
glands had formerly been 
attacked with acute inflammation, and for some 
months before death they had been the seat of 
chronic pain. In the left testis, which was the 
larger of the two, from two to three drachms of 
thick yellow inspissated pus were contained in a 
distinct cyst, which occupied the centre of the 
gland. There was no trace of tubuli seminiferi, 
but the remainder of the organ was composed of 
fibrous tissue : the sac of the tunica vaginalis was 
obliterated by close adhesions. The tunica vagi- 
nalis of the right testis contained about half an 
ounce of yellowish serum ; in the centre of the 
gland there was a small concrete abscess, but 
the tubular structure was apparent, and very little 
diseased. Pus existing in this concrete or inspis- 
sated state often keeps up pain and irritation for 



ACUTE ORCHITIS. 285 

a long period, and renders the testis liable to 
repeated relapses of inflammation. Suppuration 
occasionally takes place in the epididymis. In two 
cases of consecutive orchitis which came under 
my care, at a late period of the disease an abscess 
formed in the cellular tissue around the termina- 
tion of the epididymis and inflected portion of the 
vas deferens, and burst at the most depending part 
of the scrotum. 

In many instances, after acute orchitis has sub- 
sided the testis is restored to its natural condition ; 
in other cases, permanent changes of a serious 
nature are the consequence. I have observed in 
testes that have been affected with inflammation 
some time before, that the septa appear to be more 
distinct, and to enter more largely into the com- 
position of the gland than is natural ; that the small 
seminal tubes are less numerous and apparent ; and 
that a great part of the organ is converted into a 
dense white fibrous tissue, without the presence of 
tubuli. Sir B. Brodie gives the following account 
of the dissection of a testis which had been at- 
tacked with inflammation from a gonorrhoea twenty 
years before. It was smaller than the other testicle, 
and part of it was considerably indurated. On 
making a section of the gland, he found that about 
two thirds of the tubuli testis remained in their na- 
tural condition, while the remainder had become con- 
verted into a white substance, having the consistence 
but not the fibrous structure of ligament."^ In these 

* London Medical Gazette, vol. xiii. p. 219. 



286 ACUTE ORCHITIS. 

cases the fibrinous matter effused in the cellular 
tissue connecting the tubuli, not having been ab- 
sorbed after the cessation of inflammatory action, 
had occasioned partial atrophy of the proper struc- 
ture of the organ, and been converted into the dense 
tissue just described. Complete atrophy is one of 
the most serious results of acute inflammation of 
the testis. In Chapter II., the disturbance in the 
organization of the testis consequent upon inflam- 
mation was noticed as the most common cause of 
wasting, and several examples of it were adduced. 
Consecutive orchitis seldom subsides without leav- 
ing behind distinct traces of its existence, which 
never disappear during the remainder of the pa- 
tient's life. The epididymis frequently remains 
enlarged, presenting an indurated irregular knotty 
swelling, seated usually at its lower part, which is 
occasioned by the presence of a dense hard deposit 
between the convolutions of the duct and around 
the inflected portion of the vas deferens. On making 
a section of the epididymis in this state, I have 
often observed not only a highly thickened con- 
dition of its duct, but also, in some instances, 
very considerable dilatation ; so that the point of a 
fine probe might be introduced into the canal 
without difficulty, its area being increased four or 
five times. In old cases the epididymis acquires 
the density and consistence of cartilage, and some- 
times even those of bone. These changes are 
rarely found without the presence of old adhesions, 
obliterating partially or completely the sac of the 
tunica vaginalis. The coats of the vas deferens 



ACUTE ORCHITIS. 287 

are also found for some extent thickened and in- 
durated. The alterations noticed in the body of 
the testis have been observed, in some instances, 
co-existing with those in the epididymis ; but 
in by far the majority of cases, the glandular 
structure is unimpaired. In only two cases in 
which the epididymis was thus diseased, have I 
remarked a decidedly atrophied condition of the 
organ. The absence of pressure, owing to the un- 
resisting nature of the membrane investing the 
epididymis, appears to prevent the obliteration of 
the duct of which it is composed, and thus accounts 
for atrophy occurring much more rarely after con- 
secutive orchitis than after inflammation originating 
in the body of the gland, where the delicate seminal 
tubes are enclosed in the firm unyielding tunica 
albuginea. 

Acute orchitis may arise from various causes. 
It may be produced by contusion, as from a kick 
on the part, or a blow against the pommel of a 
saddle, the patient being jerked forwards in riding ; 
or by compression occasioned by crossing one thigh 
upon the other, or by other accidental injury. It 
sometimes appears to arise from exposure to the 
vicissitudes of the weather, in which case the in- 
flammation is liable to assume somewhat of a rheu- 
matic character. Great excitement of the sexual 
organs, without the opportunity of indulging the 
passions, may also lead to inflammation of the 
gland ; in many instances the disease is developed 
without any evident cause. 

An inflammatory swelling of the testis sometimes 



288 ACUTE ORCHITIS. 

follows an attack of cynanche parotidea, or mumps. 
It occurs generally about the period of puberty, 
and when the swelling of the parotid and sub- 
maxillary glands is on the decline : it is supposed 
to be owing to a metastasis of the inflammation 
from the salivary glands to the testis. The inflam- 
mation is usually slight, and seldom requires any 
other than mild treatment. It is commonly be- 
lieved that wasting of the testis is a frequent result 
of this complaint. Sir A. Cooper states that he 
has not met with any instance of the kind in his 
own practice f^ and no case has come under my 
observation,t nor have I heard of any amongst the 
diflerent medical friends of whom I have made 
inquiries. Dr. R. Hamilton, the first writer who 
gave a particular description of this affection, has, 
however, related two cases of atrophy of the testis 
succeeding the orchitis occurring in mumps. One 
was the case of a gentleman about forty years of 
age. On the morning of the fourth day of the 
attack the testicles began to swell. On the fifth 
day both glands were much tumefied, the right by 
far the most so. After all disease had ceased, the 
right testicle, which had been chiefly affected, 
continued gradually to waste away, till at length 
a mere empty bag, consisting of the coats only, 
remained. The second case was that of a young 



* Lib. cit. p. 77. 

f A middle-aged married man in the London Hospital on account 
of lumbar abscess had one of his testes completely wasted, which he 
attributed to an attack of mumps in his youth ; but whether correctly 
so I had no means of ascertaining. 



ACUTE ORCHITIS. 289 

man twenty-five years of age, who was attacked 
by this distemper. Upon the tumid salivary 
glands subsiding suddenly, the testicles became 
affected. One of them was much more swelled 
than the other, and was found, when the swelling 
was reduced, to be diminished more than one half 
of its natural size, at which it remained two months 
afterwards.* 

I have already observed that inflammation of the 
testis is far more frequently met with as a conse- 
cutive affection than as a primary. This gland is 
directly connected through the medium of the vas 
deferens with the urinary organs, the lining mem- 
brane of its numerous minute ducts being con- 
tinuous with the mucous membrane of the urethra. 
Any irritation, therefore, affecting that part of the 
urethra where the vasa deferentia terminate, is 
liable to be propagated to the testis, and to cause 
it to inflame. In cases of gonorrhoea, in which the 
inflammatory action has reached that part of the 
canal, or of stricture, in which the portion of the 
urethra behind the obstruction has become dis- 
eased; when the urethra has been irritated by 
foreign bodies, as calculi or instruments, or by an 
enlarged prostate gland, or disease of the vesiculae 
seminales ; in morbid states of this part, from the 
excitement of excessive onanism or sexual in- 
dulgence, and after its division and laceration in 
the operation of lithotomy, the irritation and in- 
flammation are frequently transmitted to the testis, 

* Trans, of Royal Society of Edinburgh, vol. ii. Art. IX. p. 59. 

37 



290 ACUTE ORCHITIS. 

and thus give rise to orchitis. Of all the causes 
here mentioned as more or less liable to lead to in- 
flammation of the testis, gonorrhoea is by far the 
most common. Orchitis is indeed so frequent a 
sequel of gonorrhoea, that it is generally treated of 
by writers in connexion with this affection, and 
few pathologists have drawn any distinction be- 
tween this and the idiopathic and accidental form 
of the disease. Secondary orchitis differs, however, 
from the latter, in many important respects. 

Orchitis may arise at all periods of a gonorrhoeal 
discharge, during its early and acute stage as well 
as towards its termination, though it more fre- 
quently commences when the pain and discharge 
begin to subside. It is a common observation, that 
when inflammation of the testis supervenes in 
gonorrhoBa, the pain in making water and urethral 
discharge cease altogether, or undergo considerable 
diminution, but return as the orchitis subsides ; 
which has led to the opinion that the orchitis is 
occasioned by a metastasis, or sudden translation of 
the inflammation from the urethra to the testis. 
The doctrine of metastasis, to explain the pheno- 
mena of disease, has been too often adopted on in- 
sufficient grounds. It is extremely questionable 
whether any thing of the kind ever takes place in 
gonorrhoeal orchitis. Assuredly it does not in those, 
the more numerous cases, in which the inflammatory 
action may be gradually traced creeping along the 
vas deferens to the epididymis. The origin of or- 
chitis is here clearly made out, without the neces- 
sity of being accounted for by a metastasis. In 



ACUTE ORCHITIS. 291 

these cases, nevertheless, the pain and discharge 
from the urethra diminish generally, though not 
constantly, during the early stage of the disease. 
Several of the French v\rriters have taken consi- 
derable pains in investigating the connexion sup- 
posed to exist between the state of the discharge 
and the inflammatory action in the testis. In 
sixty-seven of seventy-three cases observed by 
M. Gaussail, the discharge and other symptoms of 
gonorrhoea diminished more or less from the first 
appearance of the disease. In fifty-eight out of 
eighty-one patients noticed by M. Aubry, there 
was a considerable diminution of the discharge at 
the commencement of the attack.* M. D'Espine 
states that in six out of twenty-nine cases, the dis- 
charge underwent no modification on the accession 
of orchitis. In twenty-two cases the discharge was 
variously modified : it was either increased, dimi- 
nished, or suppressed ; but more frequently these 
modifications occurred only before or after the or- 
chitis, the amendment of which was not in general 
followed by a return of the discharge to the state 
in which it existed before the inflammation of the 
testis. In only three cases did the running, after 
having been suppressed at the commencement of 
the affection, re-appear and increase as the acute 
symptoms of orchitis subsided.t Mr. Hunter states, 
that he has known cases where the testicle has 



* Recherches sur I'Epididymite Blennorrhagique, Archives Gene- 
rales de Medecine, Mai, 1841. 

f Meraoire Analytique sur I'Orchite Blennorrhagique, Memoires 
de ]a Societe Medicale d'Observation, torn. i. p. 494. 



292 ACUTE ORCHITIS. 

swelled, and yet the discharge become more violent ; 
nay, that he has seen some instances where a swell- 
ing has come on after the discharge had ceased, 
yet the discharge has returned with violence, and 
remained as long as the swelling of the testicle.^ 
The recurrence of the pain and discharge is not 
essential to the doctrine of metastasis ; on the other 
hand, the marked amelioration of the gonorrhoeal 
symptoms cannot be regarded as adequate proof of 
its occurrence. It is well known that when a part 
becomes actively inflamed, the symptoms of inflam- 
mation going on in another part, especially if it be 
in near proximity, usually diminish, though the 
two parts are not directly connected or continuous 
with each other* The effects of blisters and other 
counter-irritants in relieving inflammation of in- 
ternal organs aflbrd a familiar illustration of this 
remark ; and I once had an opportunity of observing, 
in a case of orchitis occasioned by a blow, that the 
symptoms of a gonorrhoBa, with which the patient 
was affected at the time of the injury, subsided, as 
is often witnessed in ordinary cases of secondary 
inflammation of the gland. It is clear that Mr, 
Hunter entertained considerable doubt as to the 
influence of metastasis in these cases — a doctrine 
which was generally admitted in his day. Thus he 
remarks, ''Although an action in the urethra is the 
remote cause, yet it is still impossible to say whether 
it be the cessation of that action that is the cause 
of the swefling of the testicle, or the swelling of the 

* Treatise on the Venereal Disease, 4to. 55. 



ACUTE ORCHITIS. 293 

testicle the cause of the cessation.'"^ Inflammation 
frequently attacks the epididymis and testis of per- 
sons labouring under gonorrhoea, apparently with- 
out any previous affection of the vas deferens. It 
is in such cases only that the orchitis can be attri- 
buted to a metastasis. But when we consider how 
readily inflammatory action may be propagated 
from one part to another along a continuous mem- 
branous surface, as from the mucous membrane of 
the bladder to the kidney ; how rapidly this trans- 
mission may take place without the inflammation 
remaining fixed in any part of the continuous mem- 
brane a sufficient time to produce any evident signs 
of disease ; how rarely it happens that the gonor- 
rhoea! symptoms entirely subside as the orchitis 
becomes developed ; and how seldom orchitis occurs 
when the discharge is quickly arrested by specific 
remedies or injections ; — we cannot readily admit 
that the affection of the testis commonly owes its 
origin to the sudden cessation of disease in the 
urethra, or assent to the doctrine of a metastasis in 
these cases. 

In the sympathetic form of gonorrhoea! orchitis 
just alluded to, in which the testis is attacked, ap- 
parently without any previous affection of the vas 
deferens, the inflammation likewise commences ge- 
nerally in the epididymis. This form of the disease, 
though less common than the other, is by no means 
of unfrequent occurrence. Of one hundred and 
four cases of gonorrhoeal orchitis noted by M. Aubry, 

* T>ib. cit. ]\ 55. 



294 ACUTE ORCHITIS. 

in thirty-one the disease was sympathetic ; in the 
remaining seventy-three, the inflammation first at- 
tacked the vas deferens. It is the opinion of many 
surgeons, that inflammation of the testis most fre- 
quently arises in cases in which the discharge has 
been somewhat suddenly arrested by the adminis- 
tration of cubebs or copaiba, or the use of injec- 
tions. More mischief is perhaps ascribed to these 
remedies than they can justly be said to produce. 
I have prescribed copaiba and cubebs separately or 
conjointly in all stages of gonorrhoea, and have not 
found the patients to whom they were exhibited 
more liable to be attacked with orchitis than others 
treated differently. Mr. Broughton mentions that 
out of fifty cases of gonorrhciea treated with cubebs, 
swelling of the testicles occurred in only two in- 
stances ;* a proportion so small that it would be 
unfair to attribute the occurrence of the orchitis to 
the use of the remedy. Sir B. Brodie states, he is 
satisfied that he has seen this disease quite as often 
where no remedies, such as cubebs and injections, 
were used, as where they had been had recourse 
to.t With regard to injections, my own experience 
leads me to conclude that when employed of a 
proper strength they are very little liable to excite 
orchitis. It is only when used improperly, when 
too strong and injected too freely, so as to aggravate 
or too suddenly suppress the urethral inflammation, 
that they tend to produce inflammation in the testis. 



* Medico-Chirurgical Transactions, vol. xii. p. 100. 
t Medical Gazette, vol. xiii. p. 218. 



ACUTE ORCHITIS. 295 

According to my observation, orchitis most fre- 
quently arises in those cases in which the affection 
of the urethra is allowed to linger for want of a due 
exhibition of the remedies alluded to, particularly 
when the prostatic part of the canal is affected. 
Some pathologists have gone so far as to say that 
the chances of a swelled testis are increased in 
direct ratio to the continuance of the disease in the 
urethra."* Certainly most practitioners will allow 
that the occurrence of orchitis during the early and 
acute stage of gonorrhoea is comparatively rare. 

In chronic gonorrhoea, stricture, and morbid states 
of the prostatic part of the urethra, the patients are 
liable, especially at night, to distressing and painful 
erections, accompanied with abnormal sexual ex- 
citement and seminal emissions. In these cases 
the testis often feels heavy and uneasy, and tender 
on pressure ; and being in this irritable state is 
disposed to inflammatory action. Accordingly we 
find that slight circumstances, which would pro- 
duce no ill effects at other times, then appear 
sufficient to excite orchitis. Slight blows or pres- 
sure, much exercise, any excess in stimulating 
drinks, and neglect of the use of a suspender, are 
commonly sufficient to induce the disease. We can- 
not doubt, though it is difficult to account for it, 
that some persons are naturally more susceptible 
to attacks of orchitis than others. Thus there are 
many individuals who never contract a gonorrhoea 
without its being followed by inflammation of the 

* British and Foreign Medical Review, Oct. 1840, p. 392. 



296 ACUTE ORCHITIS. 

testis, notwithstanding every precaution taken to 
prevent the attack ; whilst there are many others, 
who, though repeatedly affected with gonorrhoea, 
yet altogether escape an attack of orchitis. ^Ne do 
not find, too, that those who suffer most severely 
from gonorrhoea are the most liable to orchitis. 
The persons most susceptible of the disease are the 
scrofulous, and those of a weak habit, who, though 
they suffer less in the first instance, find great dif- 
ficulty in getting rid of the discharge, and more 
frequently experience relapses ; whilst the robust, 
and persons of a naturally good and strong con- 
stitution, who when they contract gonorrhoea ex- 
perience its effects in the most acute form, sooner 
get rid of the disease, and more commonly escape 
its after-consequences, orchitis and stricture. 

Secondary orchitis is generally supposed to occur 
more frequently on the left side than on the right, 
but recent statistical inquiries show the fallacy of 
this opinion. Thus, in seventy-three cases of or- 
chitis observed by M. Gaussail, in forty-five the dis- 
ease was on the right side, and in twenty-four on 
the left ; four were double."^ In twenty-nine cases 
of gonorrhoeal orchitis, M. D'Espine found twelve 
on the right side, eleven on the left, and six doublet 
I have only lately registered the cases coming under 
my notice. Of thirty-six cases of consecutive or- 
chitis, twenty-one occurred on the right side, and 
fourteen on the left ; one only was double. My 
observations, therefore, agree with those of the 

* Lib. cit. p. 190. t Lib, cit. p. 443. 



ACUTE ORCHITIS. 297 

above writers in indicating the right testis to be the 
one most frequently attacked. Taking the three 
series of observations together, we have 138 cases 
of orchitis ; of these, the right testis was the seat of 
disease in seventy-eight, the left in forty-nine, and 
both glands in eleven. Reasons have been assigned 
for the more frequent occurrence of orchitis on one 
side than on the other, but they are very unsatis- 
factory ; and we can no better explain why inflam- 
mation extends along the vas deferens to the right 
testis in preference to the left, or why both are sel- 
dom attacked simultaneously, than we can account 
for the fact that the right lung is more liable to 
pneumonia than the left, or satisfactorily explain 
the comparative rarity of double pneumonia. 

Symptoms, — A testis attacked with acute inflam- 
mation in a few hours becomes swollen, hard, and 
tender, and feels heavy and painful. It increases 
to twice or thrice its natural size, but without 
alteration in its oval form. The enlargement is 
attended with a sense of weight, which is a good 
deal increased in the erect posture. The pain is 
of a constant dull aching description, usually very 
distressing to the patient. It sometimes resembles 
the uneasiness produced by squeezing the testis, 
and is accompanied with the same sickening sensa- 
tion. The pain extends upwards to the loins, where 
it is often very severe. It not unfrequently takes 
a reflex course, extending downwards to the hip, 
upper part of the thigh, and crista of the ilium, in 
the direction of the branches of the diflerent lumbar 
nerves. As the disease advances, the swollen testis 

38 



298 ACUTE ORCHITIS. 

becomes so tender that the patient can scarcely 
allow the part to be touched, and cannot bear even 
the contact of the thigh. The scrotum becomes in- 
jected, and is found red, hot, smooth, and slightly 
oedematous. 

The constitutional symptoms are usually severe. 
The pulse is rapid and hard, the skin hot, and the 
tongue white and furred. If blood be taken from 
the system, it is found cupped and buffed. The 
patient often, also, suffers from nausea and vomit- 
ing, and occasionally from pain in the lower part 
of the abdomen, which have even been mistaken for 
symptoms of enteritis. After these acute symptoms 
have existed for a period varying from forty-eight 
hours to a week or more, they begin to disappear, 
subsiding more gradually and slowly than they set 
in. But the duration of the disease is much influ- 
enced by the activity of the means adopted for its 
removal, as well as by the constitution of the pa- 
tient, 

I have stated that inflammation of the testis, 
when arising apparently from cold, sometimes as- 
sumes somewhat of a rheumatic character ; that is 
to say, the pain is periodic, and increases towards 
evening; the inflammatory action arises and sub- 
sides rather suddenly, and occurs in persons liable 
to other rheumatic affections. Dr. Macleod ob- 
serves, " I think I have several times seen rheuma- 
tism of the tunica albuginea testis. Persons sub- 
ject to rheumatism have complained of acute pain 
in one testicle coming on suddenly, accompanied 
by increased heat, and by great tenderness to the 



ACUTE ORCHITIS. 299 

touch, but without tumefaction ; the symptoms 
shifting from one testis to the other, and at last 
disappearing as suddenly as they had come on ; 
just in the manner we see rheumatism change from 
one joint to another."^ I am not able to confirm 
the observation of Dr. Macleod in respect to the 
tunica albuginea being the seat of the aifection, 
nor have I in any case found the rheumatic charac- 
ter of the symptoms very decidedly marked. 

I do not recollect having met in medical works 
with any notice of acute inflammation attacking 
the testes of young infants. I have seen, however, 
a few cases of orchitis at this early period. The 
symptoms were acute, and the swelling was con- 
siderable ; but the disease soon subsided, and it 
was always confined to one testis. A Jew child, 
only ^ve months old, was brought to me at the 
London Hospital on account of a swelling in the 
left groin and scrotum. The mother first observed 
it the day before on washing the child : he after- 
wards cried the greater part of the night. The 
tumour extended 'from the external ring to the 
bottom of the scrotum, was full six times the size 
of the right testicle, felt firm and hard, and re- 
ceived no impulse when the child cried or struggled. 
The scrotum was distended, and very red and hot. 
I ordered the application of a leech and cold lotion, 
and two drachms of castor oil to be given. In two 
days I found the swelling reduced about one third, 
and much less tender ; and the infant appeared 

* On Rheumatism, p. 20. 



300 ACUTE ORCHITIS. 

free from suffering. I directed four grains of the 
hydrarg. cum cretd to be given every night. Under 
this treatment the swelling and induration soon 
subsided, and in a week the gland was nearly re- 
duced to the size of the right testis, but the cord 
still remained thickened and hard. Three weeks 
after the attack first commenced, 1 found the parts 
perfectly natural. 

In November, 1842, I was requested to see in 
consultation a little boy, tvv^o years of age, who, on 
recovering from an inflammatory attack of the 
chest and head, was seized with an affection of the 
testis. It appeared that before his illness, there 
was a small hydrocele on the right side. A few 
days previous to my visit the scrotum became red, 
tender, and oedematous. I found a swelling of the 
right testis nearly the size of a hen's egg, which 
fluctuated in front, felt solid at the back part, and 
was hot and very tender. I considered this to be 
a case of acute inflammation of the tunica vaginalis 
and testis. The child was weak, irritable, and 
emaciated, and had recently taken mercury to some 
extent. I ordered a leech to the scrotum, the 
parts to be frequently fomented and well supported, 
and the child to be kept in the recumbent position. 
I saw him again at the end of a week. The tunica 
vaginalis had suppurated, and burst through the 
scrotum in front, and had discharged a quantity 
of thick matter. The swelling was much reduced 
in size ; but the testis as well as the cord was 
still enlarged and indurated. A small quantity 
of matter continued to be discharged. I ordered 



ACUTE ORCHITIS. 301 

quinine and a nourishing diet ; and a month after- 
wards was informed that the opening had closed, 
and that the boy was restored to health, slight 
induration only remaining at the back part of the 
gland. 

Consecutive orchitis is usually preceded by un- 
easiness in the course of the vas deferens ; the 
patient occasionally experiences distress and irri- 
tation about the bladder, and is troubled with a 
frequent desire to pass water, which is shortly fol- 
lowed by a dull aching pain and slight fulness in 
the groin. On examination of the spermatic cord, 
it feels full, and sometimes oedematous, and the vas 
deferens is found to be tender and enlarged. The 
thickening is sometimes so great, that the duct 
feels nearly as large as the little finger. The epi- 
didymis soon afterwards becomes swollen and pain- 
ful ; the tumefaction commences at the lower part or 
tail, and increases very rapidly. It forms an irre- 
gular elongated swelling at the back of the testis, 
which is sometimes fuller and larger than the gland 
itself, and extremely tender, whilst the body of 
the organ in front may often be pressed without 
causing uneasiness. The epididymis may remain 
affected for many hours, and even a day or two or 
longer, before the inflammation extends further ; 
and if checked in time it may never reach the 
tunica vaginalis, or body of the gland. In general 
the tunica vaginalis participates sooner or later ; 
and then so much tumefaction ensues that the 
inflamed mass forms an uniform tumour, in which 
the epididymis can scarcely be distinguished from 



302 ACUTE ORCHITIS. 

the other parts. In the sympathetic form of the 
disease, the swelling of the epididymis and testis 
takes place without the symptoms indicative of 
a previous affection of the vas deferens. There 
is much variety in the intensity of the symptoms. 
In some cases there is merely a slight dull pain, 
with little enlargement of the gland, and scarcely 
any constitutional disturbance. Sometimes the 
swelling is from the first very considerable, the 
volume of the gland becoming three or four times 
larger than natural, the pain being acute and con- 
stant, and the symptomatic fever severe. In other 
cases the swelling, though considerable, is quite 
indolent, and its progress slow and of long duration. 
But, in general, the symptoms continue to increase 
in intensity for several days till about the seventh 
or eighth, when they begin to disappear, the febrile 
disturbance and pain entirely subsiding, and shortly 
afterwards the tumefaction. As the swelling di- 
minishes, the epididymis becomes distinct, forming 
an indurated, knotty, and irregular swelling, at the 
back part of the testis, which often lasts for many 
months, and in many instances never disappears 
entirely during the remainder of the patient's life. 
In fifteen cases observed by M. D'Espine which 
were cured, the mean duration of the disease was 
thirty-three days and a half.^ This closely accords 
with the observations of M. Gaussail, who found 
the mean duration of seventy-three cases to vary 
from thirty to thirty-five days ;t but in my expe- 

* Lib. cit. p. 435. f Lib. cit. p. 211. 



ACUTE ORCHITIS. 303 

rience it much exceeds the period usually occupied 
by acute orchitis under suitable treatment. The 
cure of the disease is liable to be interrupted and its 
duration prolonged by relapses, which are readily 
induced by any neglect or imprudence. 

A testis which has been attacked with inflam- 
mation is afterwards more liable to orchitis than 
before. The gland, too, sometimes remains more 
sensitive ; feels uneasy under gentle pressure, or 
when the patient gets out of health ; and sometimes 
becomes painful and swollen from slight causes. 

Diagnosis. — But little difficulty is experienced 
in distinguishing a testis swollen from inflammation 
from a strangulated inguinal hernia. In both there 
may be a scrotal swelling, accompanied with pain 
and tenderness of the abdomen, frequent vomiting, 
obstinate constipation, and a good deal of constitu- 
tional disturbance. The true nature of the case, 
when these symptoms exist, can always be ascer- 
tained very readily by the absence of tension in the 
abdomen ; the limitation of the pain and tenderness 
to one side ; inability to feel the testis of its natural 
size below the swelling (supposing the hernia not 
to be congenital, and if so the history of the case 
would set all doubts at rest) ; and by the tumour 
when handled being found harder, more solid, and 
more painful than a hernial swelling, and, unless 
there is much swelling of the spermatic cord, being 
clearly defined at its upper part. When a testis 
detained in the groin becomes inflamed, the diag- 
nosis is much more difficult, a tense inguinal swell- 
ing being coupled with sickness, pain in the abdo- 



304 ACUTE ORCHITIS. 

men, and sometimes constipation. The empty state 
of the scrotum would always be sufficient to excite 
suspicion, and an active purge to set all doubts at 
rest. (See p. 112.) The active character of the 
symptoms renders acute orchitis unlikely to be mis- 
taken for the more chronic diseases of the gland. 

Secondary orchitis differs from inflammation ori- 
ginating in the body of the testis in being preceded 
by swelling, and tenderness of the spermatic cord 
and in the course of the vas deferens ; in the epi- 
didymis being invariably the part of the organ first 
affected ; in the more rapid formation and greater 
size of the swelling ; in the disease being of a more 
chronic character, and in the pain and constitutional 
suffering being less severe. It rarely leads to sup- 
puration, disorganization, or atrophy of the gland, 
but usually leaves the epididymis enlarged and in- 
durated. 

Treatment. — Acute orchitis, from whatever cause 
it may originate, must be treated with antiphlogistic 
remedies, the activity of the means being propor- 
tioned to the intensity of the inflammatory action 
and the constitution of the patient. In the gonor- 
rhoeal form of the affection, all means which may 
have been resorted to in order to arrest the dis- 
charge must be abandoned. In all cases in which 
it can be managed without inconvenience, I direct 
the patient to place himself in the recumbent posi- 
tion, either to repose on a sofa or rest in bed. The 
marked relief derived in inflammation of the extre- 
mities from promoting the return of blood to the 
heart is so fully appreciated, that it is unnecessary 



ACUTE ORCHITIS. 305 

to insist on the importance of thus obviating the 
effects of gravitation in orchitis. In very acute 
cases, this object may be more fully obtained by 
elevation of the pelvis by means of a pillov^ placed 
under the nates. The scrotum and its contents 
must also be well supported by a suspensory band- 
age. Those usually sold are often badly constructed, 
and do not fit well, so that it is necessary for the 
surgeon to see that they answer the purpose in- 
tended. In case of greasy or coloured applications 
being employed, the suspender should be lined with 
oiled silk for the sake of cleanliness, A silk, or, 
better still, a cambric handkerchief, doubled so as 
to form a triangle, the middle of the base being 
applied to the perineum, and the extremities tied 
behind, the point being carried forwards and at- 
tached in front to a band around the waist, will 
effectually sustain the scrotal parts. Patients sup- 
pose that the recumbent position obviates the ne- 
cessity for support ; but this is a mistake, much 
relief being experienced, and the effects of gravita- 
tion a good deal counteracted, by raising the testis 
from its position upon or between the thighs. A 
cold evaporating lotion, composed of lime-water, or 
the goulard and rectified spirit, in the proportion 
of one ounce of the latter to seven ounces of the 
former, or of a lotion consisting of a drachm of the 
hydrochlorate of ammonia dissolved in five ounces 
of cold spring water, with the addition of an ounce 
of rectified spirit, may be applied to the scrotum 
and frequently renewed. In the early stage of acute 
orchitis, lotions sometimes afford a good deal of 

39 



306 ACUTE ORCHITIS. 

relief; but on the whole they are less useful than 
warm applications, and can only be employed to 
advantage whilst the patient remains at rest in bed, 
as it is necessary to keep the clothes away from the 
parts in order to favour evaporation. A good-sized 
dossil of lint, surrounded with oiled silk to keep it 
moist, will commonly be found the most grateful 
and soothing application. Poultices, if not light 
and thin, occasion uneasiness from their weight, 
and when dry and harsh become disagreeable. The 
patient must abstain from taking animal food, and 
the bowels are to be acted on by a smart purge. 
Two grains of calomel, with five of the compound 
extract of colocynth, may be given at night, and 
followed in the morning by a draught composed of 
the potassio-tartrate of soda and the infusion and 
tincture of senna. A quarter of a grain of tartar 
emetic may be exhibited every three or four hours, 
and the dose, if necessary, increased until nausea 
is produced. This is one of the most valuable re- 
medies that can be employed in acute orchitis : and 
when patients are desirous of avoiding the trouble, 
mess, and exposure consequent upon the applica- 
tion of leeches, the exhibition of tartar emetic will 
generally render local depletion unnecessary, whilst 
its depressing influence being only temporary, the 
patient quickly regains his health and strength. I 
have seen most acute orchites arrested and subdued 
in thirty hours by keeping up constant nausea by 
means of this remedy. When there is much pain 
or constitutional derangement, two or three grains 
of calomel, combined with eight or ten grains of 



ACUTE ORCHITIS. 307 

Dover's powder, or with small doses of morphia, 
may be given at bedtime. In consecutive orchitis, 
in which the tunica vaginalis is so generally af- 
fected, considerable benefit is derived from mercury, 
and experience fully confirms what reason would 
lead us to expect from its remarkable efficacy in 
inflammation of the other serous membranes. The 
value, indeed, of mercury in the treatment of this 
form of orchitis, scarcely appears to be fully appre- 
ciated by the profession. In acute cases, after the 
bowels have been freely acted on, and the pulse has 
been lowered by tartar emetic, I usually prescribe 
mercury, and continue it until the gums become 
slightly affected. I am confident that by this treat- 
ment the duration of this form of the disease is often 
materially abridged, and, what is of some import- 
ance, it is succeeded by much less induration and 
thickening of the epididymis than when the exhibi- 
tion of mercury has been deferred to a later period. 
In treating cases of orchitis in private practice, 
it is generally desirable to avoid bloodletting, es- 
pecially local ; but in cases of a severe or obstinate 
character, depletion sometimes becomes necessary. 
Bleeding from the arm is only required when the 
inflammation and symptomatic fever are unusually 
acute. In a robust person, one full depletion at 
the onset of the attack in many instances consider- 
ably abridges its duration, and renders local ab- 
straction of blood afterwards unnecessary. This is 
a practice which might be resorted to more fre- 
quently than it usually is, especiafly in treating the 
working classes, to whom time and the expense of 



308 ACUTE ORCHITIS. 

leeches are objects of consideration. Local deple- 
tion, however, is more commonly employed than 
general. From eight to twenty leeches, according 
to the circumstances of the case, are applied to the 
scrotum ; and if no relief be afforded in from twelve 
to sixteen hours, they are repeated. A light poul- 
tice applied when the leeches are removed promotes 
the bleeding for some hours afterwards. The hip 
bath is also of service in encouraging the flow of 
blood, and also contributes to the relief of pain. 
After the application of leeches many persons ex- 
perience no trifling annoyance from an intolerable 
itching, which disturbs their rest at night, and in- 
duces them to scratch the scrotum until the leech- 
bites form troublesome sores. The best application 
in this state is the dilute citrine ointment ; but the 
itching may be obviated by applying the leeches to 
the skin in the course of the spermatic cord towards 
the groin, the parts being previously shaved. 

When objections are made to the application of 
leeches on account of the exposure it occasions in 
families, a sufficient quantity of blood may some- 
times be abstracted from the veins of the scrotum. 
The patient being in the erect position, distension 
of the veins is to be encouraged by fomenting the 
scrotum with warm water, or exposing it to the 
heat of a fire. Three or four veins are then to be 
punctured with a lancet. When enough blood is 
withdrawn, the patient must be directed to lie down, 
and the bleeding will almost immediately cease. I 
have removed blood in this way in several cases, 
but have not always found it flow with readiness, 



ACUTE ORCHITIS. 309 

and I have even failed in removing a sufficient 
amount. The scrotum is not always tense and 
distended, nor are the veins always apparent and 
prominent. Many surgeons recommend cupping 
on the loins : abstraction of blood in this way gene- 
rally affords relief 

The cure of acute orchitis has been much faci- 
litated, of late years, by the application of a mode 
of treatment which has been found of great service 
in relieving certain forms of acute inflammation in 
other parts of the body, viz. compression. The 
object of compression is to afford support to the 
weakened vessels ; and in acute inflammation of the 
integuments, when properly applied for this purpose, 
and not so firmly as to produce pressure and arrest 
the circulation, it often proves a very valuable 
method of treatment. Dr. Fricke of Hamburgh, I 
believe, first suggested the practice of treating both 
acute and chronic orchitis by compression, applied 
to the testis by means of adhesive plaister. In an 
early report of this practice, he states that out 
of fifty-one cases of acute orchitis eighteen were 
treated by the ordinary means, and thirty-three 
by compression. In the latter cases the average 
duration of the disease was nine days, whilst in 
the former it was thirteen. In cases treated more 
recently, after improvements had been made in the 
mode of applying the compression, the result was 
still more favourable.* This practice has since 



* Zeitschrift fur die Gesammte Medicin, as quoted in the Gazette 
Medicale de Paris, Annee 1836, p. 182. 



310 ACUTE ORCHITIS. 

been adopted in Paris by Cullerier and Ricord ; and 
in this country by Mr. Langston Parker, Mr. Acton, 
my colleague Mr. Hamilton, myself, and others, 
and, I am informed, by the army surgeons gene- 
rally. Some care is required in making the applica- 
tion, which 1 perform as follows. The patient being 
placed in the recumbent position, with the testis 
raised, is to remain there three or four minutes, in 
order to allow the vessels of the gland to become as 
empty as possible. The parts are to be shaved ; and 
some emplastrum plumhi must be cut into strips, 
about three quarters of an inch in width, and eight 
or nine inches in length. The opposite testis and 
side of the scrotum being drawn away from the 
diseased one, so as to render the integuments of the 
latter quite tense, the first strap is to be placed cir- 
cularly round the cord, just above the testis, as 
tightly as the patient can bear it. The second 
strap is to be placed in an opposite direction, from 
behind forwards, at the side of the testis near the 
septum. The third strap is to be applied below the 
first, so as partly to overlap it ; and 
the fourth in like manner, inter- 
nal to the second ; and so on in 
succession, until the straps meet, 
and the whole of the testis is 
covered, and evenly compressed. 
A few additional straps may af- 
terwards be applied where most 
needed to afford support, and keep 
the others in place ; the parts 
are afterwards to be supported in a suspensory 




ACUTE ORCHITIS. 311 

bandage. The strapping generally requires to be 
reapplied in the course of twenty-four hours. 
When the patient rises after its application he feels 
completely relieved from the aching pain and sense 
of weight ; and patients who have remained in bed 
in consequence of the pain have immediately been 
able to get up and walk about. Some surgeons 
recommend the application of compression at the 
onset of the inflammatory attack ; and if the in- 
flammation be moderate this may be done with 
advantage, so that when concealment is desirable 
the patient may be able to continue his usual avo- 
cations. But in decidedly acute orchitis it is 
better to commence with an active purge, the tartar 
emetic, and, if necessary, depletion, and to enjoin 
rest ; and then, after twenty-four or forty-eight 
hours, to resort to compression : for in active in- 
flammation of the testis compression is not always 
sufficient without other antiphlogistic means, and if 
solely depended on, may disappoint expectations. 
But after the more acute symptoms are relieved 
compression greatly facilitates the cure, affording 
relief from pain, causing the rapid subsidence of 
swelling, and removal of all effused matter. In 
cases of a chronic character, or to remove the thick- 
ening and induration of the epididymis and cord so 
commonly observed after acute consecutive orchitis, 
the testis may be strapped with the emplastrum 
ammoniaci cum hydrargyro ; or iodine or mercurial 
ointment may be first applied to the scrotum, and 
then the strapping, so as to combine the advantages 
of these applications and of compression. The 



S12 ACUTE ORCHITIS. 

renioval of the chronic enlargement and induration 
may be further promoted by the exhibition of small 
doses of mercury. In these cases I sometimes keep 
up counter-irritation by painting the scrotum on 
the side of the affected testis with the following 
solution — lodin. 3J. Potass. loclid. 3ss. *S^. Vin, 
Red, 5J.; repeating the application every third 
or fourth day, until the gland is restored to its 
healthy state. Blisters are sometimes used : but 
they are too irritating to be applied to the scrotum, 
and are even liable to cause mortification. 

In some constitutions, after the more active 
symptoms of orchitis have subsided the inflam- 
matory action persists, and continues unchecked 
even by local depletion, which, if persevered in, 
weakens the patient without subduing the disease. 
This is observed in persons of a weak frame, who 
usually appear pale, and as if they did not habitu- 
ally enjoy good health, and in whom the orchitis at 
first is neither very acute, nor accompanied with 
much constitutional disturbance. In this sub-acute 
form of the disease the pulse is quick, hard, and 
jerking ; there is but little or no fever ; but the 
digestion is usually impaired, and the testis re- 
mains swollen, tender, and painful. These patients 
do not bear depletion well. Eight or ten leeches 
applied day after day make very little impression 
on the inflammation of the testis ; but they render 
the patient weak and irritable, and retard his re- 
covery. If three or four grains of blue pill, com- 
bined with four or five of the extract of hyoscyamus, 
or ^VQ grains of the hydrargyrum cum cretd and of 



ACUTE ORCHITIS. 313 

the pulvis ipecacuanha comp., be exhibited night and 
morning, — if the diet be improved a little by allow- 
ing light broths and puddings, and the diseased 
testis be steadily strapped, I have generally found 
that the inflammatory action soon ceases, and that 
the swelling of the gland gradually subsides. 

The advice given by Bromfield and other sur- 
geons of his day in cases of gonorrhoeal orchitis, to 
introduce a bougie into the urethra, or to inoculate 
it afresh in order to bring ba:*k the discharge, was 
founded on the erroneous idea, that the acute 
symptoms of orchitis are never dissipated till the 
return of the discharge from the urethra. These 
are absurdities which the common sense of modern 
surgeons has completely banished from practice. 
Copaiba, cubebs, and remedies of this class, as well 
as injection, must not, howe er, be employed so 
long as any active disease is going on in the testis ; 
and even after all symptoms of inflammation have 
disappeared, they must be used with caution and 
in moderation. Though I have rarely found them 
give rise to orchitis, I have known them, when in- 
judiciously used, produce a relapse after all inflam- 
mation had ceased. In 1811, Mr. Ramsden pub- 
lished some observations,"^ to show that chronic 
enlargement and induration of the testis, to which 
he applied the term sclerocele, were dependent on 
some affection of the urethra, and that they were 
to be cured by remedies directed to correct the 

* Practical Observations on the Sclerocele and other Morbid En- 
largements of the Testicle, &c. 

40 



314 ACUTE ORCHITIS. 

diseased condition of tlie canal. His views never 
made much impression on the profession. He was 
wrong in regarding the disease in the uretlira as 
the invariable cause of the affection of the testis, 
instead of an occasional one ; but he committed a 
greater error in practice by chiefly applying his 
remedies to the part supposed to be the original 
source of irritation, instead of to the actual seat of 
disease, and in considering the use of the bougie 
an essential part of the treatment of these cases. 
Mr Ramsden's observations, however, were useful 
in directing attention to the frequency of the con- 
nexion between morbid states of the urethra and 
testis, which exists more commonly than was sup- 
posed. In cases of stricture, it often happens after 
an attack of acute orchitis that the epididymis con- 
tinues for several weeks, and even months, tender 
and en'arged, and the cause of annoyance to the 
patient, owing to a low degree of inflammation still 
lurking in the part. In several of these cases, after 
the stricture has been eured by instruments, the af- 
fection of the testis has subsided, without any other 
treatment being necessary than simply supporting 
the organ. I believe, too, that in the majority of 
cases in which the inflammation of the testis ex- 
hibits a tendency to return, or in which relapses 
occur, there is some disease or source of irritation 
in the urethra. In the treatment, therefore, of 
consecutive orchitis of an indolent or obstinate cha- 
racter, it is often prudent to pass a bougie in order 
to ascertain the state of the urethra. 

When suppuration occurs, the scrotum must be 



ACUTE ORCHITIS. 315 

fomented and covered with a poultice or the simple 
water dressing ; and as soon as matter can be de- 
tected by fluctuation, a lancet is to be introduced 
and the pus discharged, in order to obviate the 
sinuses and fistulous passages liable to be occasioned 
by the confinement of matter v/ithin the tunics. In 
consecutive inflammation the small isolated collec- 
tions of serum often formed between the adhesions 
of the tunica vaginalis, which fluctuate distinctly, 
and sometimes evince little disposition to disappear, 
are apt to be mistaken for deposits of pus. When 
any doubt exists, a grooved needle can be introduced 
to remove it. The opening made for the escape of 
matter should not be allowed to close too soon. 

I have not made any difference in the treatment 
of primary and of consecutive orchitis, the same 
general principles being applicable to both forms of 
the disease. But the pathological distinction which 
has been observed is not without practical interest, 
and should not be altogether lost sight of in the 
treatment of these cases. As inflammation originat- 
ing in the body of the testis is of a more destructive 
character, and more injurious to the organ than 
that commencing in the epididymis, and as the pain 
and constitutional derangement are greater in the 
former, as a general rule the treatment of primary 
orchitis should be more active than that of consecu- 
tive, and this form of the disease more generally 
requires local depletion. The prognosis in con- 
secutive orchitis is more favourable than in pri- 
mary : on the other hand, after inflammation has 
ceased, consecutive orchitis is more exposed to re- 



316 



CHRONIC ORCHITIS. 



lapses, and the swelling and induration accompany- 
ing it subside less readily and quickly than in pri- 
mary orchitis. 



SECTION II. 



CHRONIC ORCHITIS. 



The testis is liable to a form of inflammatory 
swelling of a distinct and chronic character, which 
occasionally succeeds acute orchitis, but far more 
commonly arises spontaneously. The disease is of 
importance ; for, if unchecked, it tends to disor- 
ganize and destroy the gland. 

The chief anatomical character of this form of 
inflammation is the deposit of a peculiar yellow% 
homogeneous, inorganic matter in the structure of 
the testis. This substance when 
first formed is of soft consistence, 
but afterwards becomes firm and 
solid, and so closely adherent and 
intimately blended with the proper 
structure of the organ as not to 
admit of separation without much 
difficulty. In some instances there 
is a single deposit of this substance 
in the centre of the glandular struc- 
ture, as in the preparation from 
which the annexed wood-cut was 
taken. In others several are inter- 
spersed throughout the testis, portions of sound 
gland intervening. In a case of chronic enlarge- 




CHRONIC ORCHITIS. 317 

ment of both testes, taken from a patient who died 
of ramoUissement of the medulls, sipinalis, I found six 
or seven separate deposits of this yellow matter in 
the substance of the right testis, and a single one 
only in the body of the left. The small masses as 
they enlarge coalesce, or the single one increases 
until the whole testis presents an uniform yellowish- 
white appearance. The epididymis is frequently 
invaded at the same time by a similar kind of mor- 
bid deposit, which also tends to obliterate its tubu- 
lar structure. This, however, is not, as some patho- 
logists suppose, a constant occurrence ; for in the 
majority of testes thus diseased that I have exa- 
mined, the epididymis had entirely escaped. The 
inorganic nature of this deposit is clearly apparent 
on injecting the testis, by the contrast which it 
offers to the surrounding structure. I. have never 
succeeded in tracing vessels into it. But the vessels 
of the testis generally are enlarged, and appear 
more numerous than usual. 

Pathologists have not yet determined in what 
particular tissue this yellow matter is deposited. 
Sir A. Cooper states that when a section is made of 
a testicle thus enlarged, on throwing it into water 
and agitating it a whitish yellow-fluid proceeds 
from the seminiferous tubes, which are extremely 
dilated, and which then appear emptied. But still 
the same bulk of testicle remains, owing to the cel- 
lular membrane of the part being loaded with a 
yellow fibrine or coagulable lymph ; the rete is filled 
with the same secretion as the tubuli ; the epididy- 
mis is similarly diseased ; and sometimes the vesiculie 



318 CHRONIC ORCHITIS. 

seminales and vasa deferentia are distended with a 
similar morbid secretion."^ Sir B. Brodie is of 
opinion that it is secreted from the inner surface of 
the tubiili testis. He has given an accountt of the 
examination of a testicle enlarged, and containing a 
considerable quantity of this solid yellow unorgan- 
ized substance, where, on slitting open the canal of 
the epididymis, and also the vas deferens, he found 
some of this same yellow substance adhering to 
their inner surface, having been manifestly secreted 
by the lining membrane ; and as the epididymis is 
only the termination of the tubuli testis, he con- 
cludes that in the latter the yellow substance has 
the same origin. I have recently had an oppor- 
tunity of inspecting a testis affected with this dis- 
ease in what seems to me to be its early stage, 
from which examination I think I have been able 
satisfactorily to ascertain the original seat of the 
yellow deposit. The appearances were peculiar. — 
A stout-looking brewer's labourer, aged thirty-eight, 
a married man, was admitted into the hospital, 
under the care of Mr. Luke, for an affection of the 
left testis. It appeared that four days previously 
he had strained himself in lifting some heavy casks. 
The next day the testis began to swell, and at 
length became so painful that he was induced to 
apply to the hospital for relief He stated that he 
had never suffered from any aifection of the urethra, 
and always enjoyed good health. There was a 
considerable swelling of the epididymis, which was 

* liib. cit. p. 37. 

t London Medical and Physical Journal, vol. Ivi. p. 309. 



CHRONIC ORCHITIS. 319 

at least four times its natural size, hot, and very 
tender; but the body of the testis was natural, and 
could be pressed without giving pain. He was 
kept in bed, the scrotum was repeatedly leeched, 
and mercury was given so as to affect the mouth, 
but without reducing the swelling. The tumefac- 
tion steadily increased; fluid was effused in the 
tunica vaginalis ; the veins of the scrotum became 
prominent ; the pain continued ; and about six weeks 
after the patient's admission a distinct fluctuating 
swelling appeared at the upper part of the tumour, 
which shortly evinced a disposition to point. This 
was punctured, and about four drachms of matter 
were evacuated, with some relief from pain, but 
very little diminution of the swelling. The testis 
afterw^ards continued for several weeks in a chronic 
indolent condition, with a fistulous opening dis- 
charging pus, and showing no disposition to heal. 
The man experienced no pain, and suffered scarcely 
at all in his general health ; but at length getting 
tired of a disease which seemed likely to prevent 
his returning to his employment for a long period, 
he readily consented to lose his testis. The opera- 
tion was performed rather more than three months 
after the commencement of the disease. 

The testis was injected, and a section then made 
of it. The surfaces of the tunica vaginalis were 
partly adherent, and about three drachms of serum 
were collected in one part of the sac. The body of 
the testis was not much enlarged ; it contained, 
however, an abundant deposit of a firm opaque 
matter. Near the anterior edge of the testis this 



320 CHRONIC ORCHITIS. 

deposit appeared in the section like round isolated 
yellowish-gray bodies, separated from each other 
by portions of the sound structure of the gland ; 
about the centre of the organ it assumed a beaded 
arrangement, and towards the mediastinum formed 
a number of closely set yellow lines or processes, 
radiating towards the posterior part of the testis, 
where they were amalgamated into one uniform 
mass. Further examination perfectly satisfied me 
that this matter was lymph deposited in the tubuli 
seminiferi. The isolated and beaded appearances 
in the section resulted from breaks in the lymph 
thus deposited; the real seat of the effusion was 
very evident, from the arrangement described near 
the mediastinum. With a good lens some of the 
convoluted tubuli could be distinctly seen, filled 
with and dilated by the morbid deposit. A por- 
tion v/as carefully examined in the microscope by 
Dr. Letheby, who arrived at the same conclusion 
respecting the seat of this deposit as myself The 
epididymis was much enlarged ; its head was filled 
with soft concrete matter, surrounding an irregular 
cavity with which the fistulous sinus cummuni- 
cated ; its tail contained a similar substance, with- 
out any external opening. The various appear- 
ances described are depicted in the opposite figure, 
which was drawn from the recent specimen by Mr. 
Bagg. 

The morbid appearances noticed in this case, 
though, I suspect, very little known to British 
pathologists, have been accurately described and 
figured by Cruveilhier, in his Anatomic Patho- 



CHRONIC ORCHITIS. 



321 




logique * He states, that of all the forms of sarco- 
cele this is without doubt 
the most frequent. It is 
that which appears con- 
stantly to succeed to vene- 
real affections incomplete- 
ly cured, and to chronic 
inflammation consequent 
upon contusions ; in fact it 
is the most general form of 
sarcocele, developed under 
the influence of an acci- 
dental cause ; and he has 
been led by a great number of facts to regard this 
alteration as the result of a chronic inflammation 
of the epididymis. The disease proceeds from 
the swollen head or extremity of the epididymis 
towards the tail. The body of the testicle is 
only affected consecutively. I believe myself that 
the yellow deposit is the ordinary result of chronic 
inflammation of the testis, in whatever way pro- 
duced ; but that the peculiar appearances noticed 
in the case just related, and which have likewise 
been described by Cruveilhier, — I mean the small 
isolated masses in the substance of the gland, and 
radiated form of the deposit towards the medias- 
tinum, — are only observed in those cases in which 



* Liv. V. pi. 1, and liv. ix. pi. 1. 



K. 1. Fistulous sinus leading to the suppurating- cavity in the head 
of the epididymis. 
2. Concrete abscess in the tail of the epididymis. 
41 



322 CHRONIC ORCHITIS. 

the disease originates in the epididymis, and thence 
spreads to the body of the testis, and in which 
the part is examined before the organ has be- 
come extensively diseased. These appearances 
are not often seen, because it is not often that it 
becomes necessary to remove a testis in that con- 
dition, which is indeed a curable one, unless com- 
plicated with suppuration. Cruveilhier supposes 
that this matter is effused in the cellular tissue of 
the testis, and radiates along the fibrous prolonga- 
tions from the corpus highmori. I feel satisfied, 
however, from my own observations, that he is mis- 
taken, and that the interior of the tubuli is the 
original seat of the deposit. 

This yellow substance has been called the yellow 
tubercle of the testis ; but as it differs from tuber- 
cular deposit, which is also developed in the testis, 
the term is objectionable, and liable to lead to error. 
It appears to be coagulable lymph, which becomes 
more solid in the testis than in most other parts, 
owing, perhaps, to the condensation consequent on 
the firm resistance offered to any enlargement of 
the gland by the unyielding tunica albuginea. That 
lymph effused in a part so well supplied with ves- 
sels should long remain unorganized scarcely seems 
remarkable, when we recollect what little disposi- 
tion it evinces to undergo this change when depo- 
sited on mucous membranes, and in the interior of 
other glands. Lymph may remain for years in the 
cells of the cellular tissue without becoming organ- 
ized, as is often observed around a diseased joint ; 
and the compactness and firmness of this deposit 



CHRONIC ORCHITIS. 323 

within the testis are circumstances unfavourable to 
the developement of new vessels. This disease is 
often accompanied with effusion of serum into the 
tunica vaginalis, seldom amounting, however, to 
more than three or four ounces. Lymph also is 
sometimes poured out on this membrane, and the 
sac becomes partially or totally obliterated by ad- 
hesions. 

The peculiar matter effused in this disease under 
appropriate treatment undergoes complete absorp- 
tion, the testis being left in a condition to perform 
its natural functions. It sometimes happens, how- 
ever, that ulceration ensues in its tunics and 
integuments, and that a fungous-looking growth 
gradually protrudes through the opening which is 
thus formed. This fungous growth, or as it is 
sometimes termed granular swelling, may without 
impropriety receive the name o^ hernia testis ; being 
formed in a manner very analogous to that of a 
hernia cerebri, in which the substance of the brain 
is protruded through an ulcerated opening in the 
dura mater. It appears that the yellow deposit 
after some time excites ulceration in some part of 
the tunica albuginea. The tunica vaginalis, and 
afterwards the skin, become adherent at this spot, 
and likewise inflame and ulcerate. The resistance 
afforded by the dense unyielding tunica albuginea 
being thus removed, the adventitious deposit gra- 
dually presses out the tubular structure, which 
forms a projecting tumour constituted of the tubuli 
testis mixed up with this yellow substance, and 
also of ordinary granulations which spring up from 
the seminiferous structure. (See wood-cut, p. 342.) 



324 CHRONIC ORCHITIS. 

It is only in recent years that this hernial pro- 
trusion of the structure of the testis has attracted 
particular attention. In 1808, Mr. Lawrence ex- 
plained the true nature of the affection in a paper 
illustrated with several cases f and his observations 
on its causes, syniptoms, and progress have been 
confirmed by all succeeding writers on the diseases 
of the testis. Though this hernial growth occurs 
most frequently in an advanced stage of the chronic 
form of inflammation, it is developed in other dis- 
eases of the organ which occasion ulceration of the 
tunica albuginea, and thus afford an opening for 
the escape of its contents. It is occasionally the 
result of an attack of acute inflammation super- 
vening upon the chronic disease, and terminating 
in suppuration in the substance of the gland. In 
a case of this kind, in addition to the glandular 
swelling there are sinuses, more or less numerous, 
which burrow in the interior of the organ, and 
discharge pus mingled with the yellow matter. 
An attack of orchitis originally acute, going on to 
suppuration, is also liable to be followed by a fun- 
gous protrusion of the secreting structure of the 
gland. In the latter case the growth is not so 
exuberant, and the seminiferous structure is more 
distinctly apparent, owing to the absence of the 
yellow matter ; but there are generally sinuses 
which furnish a purulent discharge, sometimes 
mixed with semen. Tubercular matter deposited 
in the testis may also lead to suppuration, and the 
formation of a granular swelling. 

* Edinb. Medical and Surgical Journal, vol. iv. p. 257. 



CHRONIC ORCHITIS. 325 

A testis, after becoming somewhat enlarged from 
chronic inflammation, often continues indolent and 
stationary for years, giving rise to very little incon- 
venience. On examining the organ in this state, 
the yellow adventitious deposit is found to possess 
considerable firmness and consistency ; the tunica 
albuginea is thickened, and in some places as dense 
and indurated as cartilage ; and the surfaces of the 
tunica vaginalis are closely connected by old adhe- 
sions. The glandular structure is partly displaced 
and atrophied by the pressure of the yellow matter ; 
and it often happens after some time that both 
undergo a slow process of wasting, so that an en- 
larged and indurated gland is progressively reduced, 
until scarcely any thing remains beyond a mere 
nodule of the size of a nut at which the spermatic 
cord terminates, 1 found, on examination of the 
body of a man who some few years previously had 
suffered from chronic inflammation of the testes, 
both glands much indurated, but about the natural 
size. In both the tubular structure was very defi- 
cient, its place being supplied by a dense fibrous 
tissue. At the upper part of the right testis there 
was a yellowish deposit almost as dense as cartilage, 
and exhibiting very little trace of vascularity. A 
testis in this indolent state, when examined in the 
hand, often feels as hard nearly as a stone ; and 
formerly the term schirrus was commonly applied 
to such enlargements. Its employment to designate 
this morbid state of the testis is scarcely exploded 
even now ; but the term is objectionable, being 
liable to convey the erroneous impression that the 



^^j^^l 



326 CHRONIC ORCHITIS. 

disease is of the same nature as schirrous mamma, 
whereas it is of quite a different nature, and rarely 
if ever assumes a malignant character. In these 
indurated testes, the epididymis often escapes the 
morbid alteration affecting the body of the gland ; 
in other cases, however, the epididymis is also 
found nodose, irregular, and hard. 

It will be perceived, from the preceding observa- 
tions, that the tendency of this chronic disease is 
gradually to destroy the integrity of the testis. If 
the inflammation be checked in an early stage, the 
gland is left unimpaired ; if its course be not arrested 
until a later period, the secreting structure is partly 
disorganized and reduced in size ; but if the disease 
be allowed to continue unchecked by treatment, 
the organ is totally destroyed, either by ulceration 
of its tunics and the escape of the glandular struc- 
ture in the shape of a fungous growth, or by the 
slower process of wasting and absorption. 

The causes of chronic inflammation of the testis 
are various. It often takes place after a slight con- 
tusion, the first effects of which were so inconsider- 
able as to be very little regarded by the patient, the 
testis not beginning to swell nor to give pain till 
some weeks after the accident. Occasionally it 
arises a short time after the cessation of an attack 
of acute orchitis, more particularly when the patient 
has been guilty of some imprudence. It occurs also 
after excess in venery and frequent masturbation. 
Persons suffering from stricture, and other affec- 
tions of the urinary organs causing irritation in the 
urethra, are peculiarly liable to it ; and the inflam- 



CHRONIC ORCHITIS. 327 

mation may sometimes be traced creeping along 
the vas deferens to the epididymis, and thence to 
the testis, as in consecutive orchitis. It occasionally 
arises during an attack of gout, and in persons 
suffering from rheumatism, in which cases it has 
partaken of the characters of these constitutional 
maladies. Sir A. Cooper's observations on this 
subject are very valuable, as the result of large 
experience. He remarks, " With respect to the 
causes of this disease, it is wrong to view it merely 
as a local affection ; for there is in persons prone 
to this complaint a constitutional tendency to the 
malady. It often occurs in those who have been 
scrofulous in their youth. It is frequently the 
product of a constitution worn and broken by in- 
temperance. It often follows a long-continued 
course of mercury ; and it arises in habits in which 
the vital powers are diminished, and in which we 
so often find sloughing of the cellular membrane, 
in the form of chronic carbuncle. Frequent ex- 
posure to wet, cold, or fatigue, and an excessive 
indulgence of the passions, also dispose to its pro- 
duction. The most frequent occasional cause is 
urethral disease, whether it be irritation only, ex- 
citing a sympathetic influence, or an organic change 
in the mucous membrane; and many of those causes 
which I have mentioned, in speaking of acute in- 
flammation of the testes, are in different cases, the 
precursors of this disease ; the chief difference in 
the nature and production of the two complaints 
being in the state of the constitution."^ 

* Lib. cit. p. 39. 



328 CHRONIC ORCHITIS. 

Symptoms. — The symptoms of this disease are 
uniformly of an indolent character. At the com- 
mencement of the inflammatory action the testis 
feels somewhat tender ; and after a short time the 
patient detects a slight enlargement, and an irre- 
gular induration in some part of the organ. This 
induration often commences at the lower part of the 
epididymis ; but not always, nor so frequently as is 
supposed by many pathologists. The body of the 
gland and the epididymis shortly become involved 
in one common swelling, which feels smooth, firm, 
inelastic, and of uniform consistence, and is of an 
oval form, with the sides somewhat flattened. The 
enlargement advances slowly, but goes on steadily 
increasing until the organ is at least twice its 
natural size. The swelling is attended with slight 
pain of an obtuse character, and a sense of weight 
in the part and in the loins. The pain on pressure 
is also dull; and when the disease continues for 
seven or eight weeks or longer, the organ loses in a 
great degree its peculiar sensibility. The spermatic 
cord is not generally indurated ; but it feels full, 
and its veins are rather swollen. Formerly the 
term sarcocele was indiscriminately applied to this 
morbid state of the testis, as well as to other en- 
largements of the gland of a very different nature. 
The confusion produced by confounding various 
affections under one common appellation is a suf- 
ficient reason for the discontinuance of the use of 
this term, which is now seldom met with in surgi- 
cal works. There is often some effusion in the 
vaginal sac around the enlarged testis, constituting 






CHRONIC ORCHITIS. 329 

the affect ion to which the term hydrosarcocele has 
been applied. The effusion is seldom considerable ; 
indeed I have rarely found it exceed eight ounces. 
It is frequently collected at one spot, its diffusion 
throughout the sac being prevented by old adhe- 
sions. 

It often happens that both testes become affected, 
inflammation having commenced in one gland 
shortly after the enlargement of the other, or, hav- 
ing ceased in one, then appearing in the other. 
Sometimes fluid is effused only on one side ; in other 
cases there is double hydrocele, coupled with morbid 
enlargement of both testes. 

So little inconvenience is usually experienced 
from this disease, that the testis often acquires a 
considerable size before the patient's attention is 
seriously attracted to it. He finds relief, perhaps, 
from a suspensory bandage, and continues his usual 
occupations, exercise, and mode of living, without 
paying any further attention to it, until fresh in- 
flammation is excited by a slight blow, or excess in 
drinking or venery ; when, the symptoms becoming 
suddenly severe or increased, he is induced to seek 
for surgical assistance. 

After the disease has existed for many weeks, or 
even months, the skin at some part of the scrotum, 
usually the front, grows thin and prominent, and 
becomes red and inflamed. In a short time it 
breaks, and a fungous-looking substance, and some- 
times a small quantity of pus, are discharged ; and 
this is soon followed by a hernial protrusion of the 
substance of the testis, which gradually increases, 

42 




330 CHRONIC ORCHITIS. 

until the part presents the characteristic appearance 
of the granular swelling. This consists of a pro- 
tuberant mass, presenting an ash or yellowish-white 
appearance, varied by irregular patches of a pale 
red hue, and sometimes of black. This projecting 
growth is surrounded and often closely girt by the 
skin of the scrotum, the ulcer- 
ated edges of which are thick- 
ened and everted. It furnishes 
a scanty thin sanious discharge, 
occasionally mixed with the 
seminal fluid. It is nearly 
insensible to friction, the ac- 
tion of caustics, and incisions 
with the knife. The sperma- 
tic cord may be distinctly traced to the base of 
this morbid protrusion of the gland, v^hich often 
projects so much that scarcely any part of the 
organ can fairly be said to be contained within the 
scrotum. The disease in this stage is very indo- 
lent, and if not interfered with lasts many months 
without undergoing any perceptible change. As 
soon as the scrotum has thus given way all pain 
abates, and the scrotal swelling partly subsides. 
Very few cases of hernial protrusion of the testis 
have come under my notice within the last few 
years. The disease appears to reach this stage less 
commonly in the present day than was the case 
formerly. Cases of granular swelling were cer- 
tainly of more frequent occurrence in 1826, when I 
first commenced attending the practice of the Lon- 
don Hospital, than they have been of late years. 



CHRONIC ORCHITIS, 331 

The circumstance must be ascribed to the profession 
generally having become better informed in the 
diseases of the testes, and to the success attending 
their improved treatment of the earlier stages of 
the affections of this gland. 

I have spoken at page 276 of the deposition of 
matter in the substance of the testis and epididymis 
in cases of acute orchitis, and have mentioned the 
concrete form of this deposit, and chronic state of 
the symptoms which occur after all active disease 
has subsided. Suppuration occasionally takes place 
in the chronic form of orchitis, which I am now 
describing, in connexion wath the formation of the 
yellow deposits of lymph. Both pus and lymph 
may be effused in the substance of the testis ; or 
lymph may be deposited in the testis, whilst sup- 
puration occurs in the epididymis alone, as in the 
case related at page 342. The formation of pus in 
these cases is a serious aggravation of the disease, 
and much lessens our prospect of being able to 
save the testis. When effused in the body of the 
gland it disorganizes the delicate structure ; and 
when ulceration ensues and the matter escapes, 
leaves behind sinuses communicating with the in- 
terior of the organ, which evince but little disposi- 
tion to close. These sinuses discharge a thin pus, 
mixed in some cases with the seminal fluid, forming 
consequently a spermatic fistula. We cannot, of 
course, treat these sinuses as we should similar 
passages in other parts, by injecting them, or lay- 
ing them open from the bottom. We can only en- 
deavour to remove any existing disease by the 



332 CHRONIC ORCHITIS. 

ordinary remedies for chronic inflammation, in the 
hope that as the health improves they may be in- 
duced to heal. Their cure may be a good deal 
promoted by keeping the testis steadily compressed 
by means of strapping. In some instances these 
fistulous passages prove so tedious, and so affect 
the general health, that it becomes desirable to 
resort to the operation of castration. I have already 
described a case in which it became necessary to 
adopt this proceeding, and I once witnessed the 
removal of a testis from an elderly man on the 
same account. On examination the epididymis was 
found encased in the serous m.embrane, much in- 
durated and thickened ; the tunica vaginalis con- 
tained a quantity of serum. There were three 
distinct deposits of inspissated pus in different parts 
of the epididymis, and at its lower part a suppu- 
rating cavity, lined by a rough-looking membrane: 
the cavity opened externally by a fistulous passage 
leading to the bottom of the scrotum. The body 
of the testis was quite sound. The patient had 
suffered from the disease for eight months, and it 
had resisted the ordinary treatment. In cases, too, 
of pus effused in the testis without finding any 
vent, there is often an indolent intractable enlarge- 
ment of the gland, which continues stationary, 
does not yield to remedies, and is attended with 
very little or no pain ; but still causes so much 
annoyance to the patient, and so disturbs his mind, 
that he becomes desirous of parting with the organ 
in order to regain his health and resume his cus- 
tomary occupations.— In March. 1841, I was re- 



CHROxMC ORCHITIS. 333 

quested to visit the master of a ship, a man aged 
forty-three, in consequence of a chronic enlargement 
of the right testis, which had been gradaally forming 
for many months. The mouth had been made sore 
by mercury, and various stimulating applications 
to the part had been used, v^ithout any effect on 
the disease. He did not suffer much, and was 
desirous of returning to his ship ; but Mr. Arthur, 
his medical attendant, considered it unsafe for him 
to go to sea again with such a disease unrelieved. 
As the swelling had not subsided under the re- 
medies which had been judiciously tried and per- 
severed with, I recommended the removal of the 
gland, to which the patient readily consented, rather 
than submit to any long confinement. I accord- 
ingly performed the operation, from which the 
patient recovered, so as to be able to join his ship 
in a month. The testis was enlarged to more than 
thrice its natural size. The surfaces of the tunica 
vaginalis were closely adherent. On making a 
section of the tumour no trace of the natural tex- 
ture of the gland was apparent, its place being 
supplied by irregular masses of lymph and soft 
purulent deposits, separated by septa of ligamentous 
tissue. 

In some instances, when pus is pent up in the 
testis, the organ continues enlarged and tender, 
and the seat of a dull chronic pain, the matter 
proving a continual source of irritation. These 
symptoms may be relieved by rest, local depletion, 
and mercury ; but the benefit is in general only 
temporary, the patient continuing to suffer more 



334 CHRONIC ORCHITIS. 

or less, and frequently experiencing relapses. For 
this state of the organ there is seldom any other 
remedy than castration. The following case is 
related by Sir A. Cooper. " A surgeon in the 
cavalry had an inflammation and chronic enlarge- 
ment of the testicle, which had been repeatedly 
relieved by the recumbent position, local depletion, 
and the use of mercury ; yet when he returned to 
the exertions necessary to the due performance of 
his military duties, the symptoms were renewed. 
Tired by these repeated disappointments, and un- 
able to pursue his profession satisfactorily, he re- 
quested me to remove the part, to which I con- 
sented, and found, upon dissection of the testis, a 
chronic abscess in the centre, which kept up irri- 
tation of the part, and repeatedly reproduced the 
inflammation."* In cases of this nature the pre- 
sence of pus cannot be ascertained with any degree 
of accuracy. No surgeon, therefore, would think 
of resorting to castration till after a persevering 
trial had been made, with the usual remedies for 
the reduction of chronic inflammation of the gland. 
Sir A. Cooper has remarked that the testis, even 
in very young children, sometimes becomes enlarged 
and very hard, but without pain or any inconve- 
nience ; and the disease is accidentally discovered 
by the parent or servant. In this state of indolent 
increase it remains for many weeks, months, or 
years ; and then, under improvement of the genera 
health, the enlargement subsides, and the gland re- 

* Lib. cit. p. 44. 



CHRONIC ORCHITIS. 335 

sumes its natural state.^ No case of this descrip- 
tion had come under my notice till, very recently, 
Mr. Hamilton kindly showed me an infant ten 
months old, who was under his care at the London 
Hospital on account of a chronic enlargement of 
both testes. These glands were observed to be 
rather large at birth, but they had since greatly in- 
creased in size. The right was nearly as large as 
a plover's egg: the left was somewhat smaller. 
They were of an oval shape, and quite hard, had a 
smooth and even surface, and did not appear at all 
tender when handled. The infant was in pretty 
good health. The case had been under Mr. Hamil- 
ton's care three weeks, during which time they had 
remained stationary. I have no means of ascertain- 
ing the pathological nature of this chronic enlarge- 
ment of the testis in young infants; but I question 
whether Sir A. Cooper is correct in describing the 
disease as of a tubercular character. The fact that 
the enlarged gland usually resumes its natural state, 
and the even character of the swelling, are unfavour- 
able to this view of the nature of the tumour. 

Diagnosis. — A chronic inflammatory enlarge- 
ment of the testis may be mistaken for encephaloid 
cancer of the organ, and for a haematocele. It 
differs from the former in the surface of the gland 
being more uniform and regular, in the tumour 
being of less size, and in the absence of any con- 
comitant affection of the cord and lymphatic glands 
in the groin. In many cases the origin of the 

* Lib. cit. p. 97. 



336 CHRONIC ORCHITIS. 

disease in the epididymis also serves to indicate the 
nature of the case. In the early stage, however, 
of encephaloid cancer, the characters of the tumour 
are so similar to those of the present disease that 
the diagnosis is extremely difficult. The tumour 
produced by chronic orchitis is more solid, and not 
so elastic as a hcematocele. It very rarely, too, 
attains so large a size as the latter, v^ithout causing 
ulceration of the tunica albuginea, and a hernial 
protrusion of its glandular structure. On inquiry 
into the history of the case the disease will be found 
to have come on very gradually, and not to have 
occurred suddenly after a blow, or to have suc- 
ceeded a hydrocele, as is the case with a hoema- 
tocele. The diagnosis is usually very easy ; indeed, 
I have not witnessed any case of chronic orchitis 
in which there was any difficulty in distinguishing 
the disease from a hsematocele. A hydrosarcocele 
can only be distinguished from a hydrocele by an 
examination of the part, after the fluid has been 
evacuated, unless the serous effusion be very small 
in quantity, or the sac should happen to be loose 
and not fully distended, in which case the enlarged 
and indurated gland may be detected through the 
fluid. 

Treatment. — Chronic orchitis, if treated early, is 
usually very amenable to remedies. Depletive mea- 
sures are seldom necessary. A few leeches may 
sometimes be applied with benefit after a fresh or 
sudden accession of inflammation ; but even local 
depletion is not often required. Mercury is the 
chief remedy ; and there are few other diseases in 



CHRONIC ORCHITIS. 337 

which its effects are more uniformly beneficial, or 
in which it is better entitled to be regarded as a 
specific, than in chronic orchitis before the occur- 
rence of suppuration. As soon as its influence on 
the system begins to be manifested, the pain and 
tenderness cease, the sw^elling diminishes, and the 
induration gradually disappears. Five grains of 
blue pill, with a quarter of a grain of opium, may be 
given twice daily ; and the dose can afterwards be 
increased or diminished according to its effects. 
No object is gained by making the mouth very sore ; 
but it is desirable to affect the gums slightly, and 
to keep the patient under the influence of the 
remedy until all swelling has subsided, and the 
induration is nearly removed, which takes place 
slowly, and usually occupies three or four weeks. 
I prefer the blue pill, because the continued action 
of the remedy in this form produces less irritation 
in the system than calomel. It must not be under- 
stood that chronic orchitis cannot be cured without 
mercury ; but this remedy is so eminently bene- 
ficial, that where the constitution can bear it its 
exhibition should always form an important part of 
the treatment. At first I generally recommend the 
patient to keep constantly in the recumbent posi- 
tion, in bed or on a sofa ; but this is not absolutely 
necessary, and may often be dispensed with during 
the treatment and when the inflammation is slight. 
Compression by means of strapping, applied in the 
manner already explained, tends to promote the 
absorption of the adventitious deposit, and hasten 
the resolution of the swelling. The eflicacy of mer- 

43 



33S CHRONIC ORCHITIS. 

cury is so great that I have seldom employed com- 
pression without it, but I have several times com- 
bined the two apparently with much benefit. In 
these cases I generally strap with the emplastrum 
ammoniaci cum hydrargyro. Dr. Fricke of Hamburgh 
and Mr. Langston Parker^ also speak favourably 
of the effects of compression in chronic orchitis. 
The reduction of the swelling and induration may 
also be promoted by applying to the scrotum the 
strong mercurial ointment, or by counter-irritation 
from the application of the Unguentum lodinii C, 
or the Ceratum Hydrargyri C. In cases in which I 
have been desirous of not increasing the mercurial 
influence, I have somxCtimes kept up irritation by 
painting the scrotum every alternate day with the 
tincture of iodine. These local applications are 
particularly applicable to those cases in which the 
presence of fluid in the tunica vaginalis prevents 
the advantageous use of compression. It is often 
necessary to continue the local means and the 
exhibition of small doses of mercury for several 
weeks, before the eflects of the disease are entirely 
removed. But it is not necessary that the patient 
should be strictly confined all this time. He may 
pursue his usual occupations in-doors, and even 
take gentle exercise in the open air. One great 
advantage of compression is, that it dispenses with 
confinement to the recumbent position in most of 
the cases in which it is employed. In cases where 
I have found it necessary to discontinue the use of 

* Lancet, vol. ii. 1839-40, p. 640. 



CHRONIC ORCHITIS. 339 

mercury in consequence of its injurious effects on 
the constitution, the decoction of sarsaparilla, with 
five or six grains of the iodide of potassium, has 
been given with much apparent benefit in getting 
rid of the swelling and induration. In gouty and 
rheumatic constitutions, colchicum combined with 
anodynes may often be exhibited with advantage. 
During the treatment the patient must strictly 
abstain from the excitement of venery ; and the diet 
should be light, and malt liquors and stimulating 
drinks must not be allowed. 

The successful result of this treatment necessarily 
much depends upon the period at which the case 
comes under the surgeon's care. If the disease has 
not existed longer than five or six weeks, the 
restoration of the testis is complete ; but if its 
duration be greater, the structure of the gland often 
suffers, though the organ may still be saved from 
complete destruction. When inflammatory action 
has been allowed to go on for many months, the 
testis generally becomes so disorganized that all we 
can hope for is to arrest the progress of a disease 
which is a source of suffering, keeps up irritation, 
and tends to impair the general health. 

As the inflammation of the testis subsides, the 
fluid effased into the vaginal sac usually becomes 
absorbed ; so that the hydrocele seldom requires any 
other treatment than that -employed for the removal 
of the disease which produces it. Sometimes, how- 
ever, these means prove insufficient to get rid of 
the hydrocele, and an operation becomes necessary 
to make a complete cure. There should be no 



340 CHRONIC ORCHITIS. 

hurry in resorting to active measures for this pur- 
pose ; for it often occurs as the patient recovers 
from the effects of the disease and the treatment, 
and his health becomes fully re-established, that 
the fluid in the tunica vaginalis is slowly absorbed. 
When, therefore, after the removal of the disease of 
the testis, the quantity of fluid is so considerable as 
to produce a tumour of inconvenient size, the sur- 
geon should perform acupuncture, or introduce a 
trocar, and having drawn off the fluid wait the re- 
sult. If it should collect again he can then have 
recourse to injection ; a remedy which, under these 
circumstances, must be employed with some cau- 
tion, in order to avoid exciting fresh inflammation 
in the substance of the gland. 

The following case will serve to illustrate many 
points in the history and treatment of this affec- 
tion, — A captain of a ship, a man of swarthy 
complexion and muscular frame, £et. 27, who 
had just returned from a voyage to the West 
Indies, was brought to me October 1st, 1840, by a 
medical friend, for my opinion respecting the state 
of his testes. It appeared that the right gland had 
begun to swell about a twelvemonth previously, 
and that six months afterwards the left had also 
increased in size, and they had since continued to 
enlarge. The inconvenience which he suffered was 
so slight that no attention had been paid to his com- 
plaint, which did not appear to affect his health. 
He was engaged to undertake another voyage in a 
few days ; but he thought proper to consult his 
usual medical attendant before joining his ship. 



CHRONIC ORCHITIS. 341 

On examination I found a hydrocele of moderate 
size on the right side of the scrotum, and could 
without difficulty detect the testis behind by the 
solidity and firmness of the tumour at this part, 
which were greater than usual. There was a hy- 
drocele also on the left side, which was of an oblong 
shape, and extended some way up the cord ; but 
owing to the looseness of the sac, and the presence 
of only a small quantity of fluid, I could easily feel 
the left testis, which was evidently enlarged and 
indurated. It was rather tender, but not much 
more so than usual, and the slight inconvenience 
which the patient experienced appeared to arise 
from the size and weight of the tumours. I drew 
off about six ounces of straw-coloured serum from 
the hydrocele on the right side with a trocar, and 
then found this testis larger even than the left, and 
also very hard. In both the induration was in the 
body of the gland, and not particularly in the 
epididymis. The spermatic cords appeared to be 
unaffected. He stated that he had not been subject 
to any complaint of the urinary organs during the 
last two years, and he ascribed the origin of the 
disease of the testicles to excessive venereal indul- 
gence. The importance of abandoning his inten- 
tion of shortly going to sea was strongly urged; and 
it was with some hesitation consented to, being at- 
tended with serious inconvenience. The following 
treatment was adopted : — Rest in the recumbent 
position; three five-grain blue pills in the day; 
and the application of the Unitnentum liydrargyri 
to the scrotum,— Oct. 17th. Although the pills 



342 CHRONIC ORCHITIS. 

had been increased to four daily, the mouth was 
scarcely at all affected by the mercury. The tes- 
tes were less tender, and a little diminished in size. 
The hydrocele on the right side returned a few 
days after the operation. He was now ordered to 
rub in a drachm of strong mercurial ointment on 
the inside of the thighs night and morning, and to 
take two blue pills daily. On the 22d the mouth 
was rather sore, and the fluid was entirely absorbed 
from the left side ; and the testis was softer, and 
partly reduced in size. The right testis and hy- 
drocele were also diminished. The treatment was 
continued. — Nov. 3d. The mouth was very sore : 
the blue pills had been omitted since the 27th ult. 
Both testes were much diminished in size ; but they 
felt irregular, and were still heavier and harder 
than natural. A small quantity of fluid was yet 
remaining in the tunica vaginalis on the right side. 
I ordered Decoct. Sarzce. cum Potass. lodid, gr, v. 
ter die ; pil. hydrarg. gr. ij. o. n. ; and the scrotum 
to be painted every alternate day with Tinct. lodiniL 
This treatment was continued for about two weeks. 
The patient w^as allowed good diet, and to take 
exercise ; and as his health became re-established 
all effusion disappeared, and both testes were re- 
stored to their natural size, a little induration only 
remaining at the end of ten weeks after I first saw 
him. 

Not many years back a hernial protrusion of the 
testis was regarded as so formidable and incurable 
a disease, that no other treatment was resorted to 
but castration. A better acquaintance with the 



CHRONIC ORCHITIS. 343 

pathology of this gland has led to improvements in 
practice, and now the majority of cases of this af- 
fection are found to be remediable without recourse 
to so severe an operation. Indeed, I believe with 
Mr. Lawrence that, in many instances, if the com- 
plaint were left entirely to itself the swelling would 
subside, the fungus shrink, and a complete cure 
ensue without any professional assistance."^ The 
chief obstacle to the healing of the wound is the im- 
pediment offered by the protuberant fungous mass. 
The first object, therefore, is to reduce this pro- 
jecting growth to the level of the surrounding skin. 
Mr. Lawrence recommended its removal with the 
knife, as the shortest and most effectual mode of 
treatment. Sir A. Cooper states that he has several 
times successfully practised the following plan : — 
" An elliptical incision is made in the skin around 
the projecting granulations, and then the knife is 
carried under the whole of the swelling, and close 
to the tunica albuginea ; by which the part is 
excised, leaving the epididymis and testicle unin- 
jured. Then the edges of the skin are approximated 
over the new surface, and it is healed by adhesion, 
if possible ; but, if the adhesion be not complete, by 
pressure with adhesive plaister ; and by approxi- 
mation of the integuments over the orifice of the 
tunica albuginea, the granulations are prevented 
from becoming again prominent."t The protrusion 
may be remedied and the sore healed without 
recourse to the knife, and I must confess that the 

* Lib. cit. p. 258. f Lib. cit. p. IS, 



344 CHRONIC ORCHITIS. 

operation of excising it scarcely seems to be a very 
scientific mode of proceeding. It has been seen 
that the projecting fungus partly consists of tubuli 
seminiferi, and in some instances includes nearly 
the whole of the glandular part of the testis, so 
that its removal becomes an operation which in 
effect is but little less than that of castration. It 
may, indeed, be doubted whether the secreting struc- 
ture protruded in this affection can ever be so far 
restored as to be enabled to perform its proper 
function ; and in some instances, after the fungus 
has receded and the part become healed, the testis 
has been reduced to an atrophied and useless con- 
dition. Still it is by no means clear that in most 
of these cases of hernia testis the glandular struc- 
ture, though more or less injured, is wholly de- 
stroyed, or incapable of recovery. That the tubuli 
are capable of secreting whilst projecting from the 
scrotum has in a few instances been proved by the 
appearance of semen in the discharge ; and I see no 
reason why they should not be able to continue 
their functions after the testis haB resumed its 
situation, and the sore has closed up. I think the 
object of the surgeon should be to endeavour to 
place the diseased organ as nearly as possible in its 
former healthy condition, and the greater his success 
the more perfect will be the character of his prac- 
tice. Upon this principle the extirpation of any 
part of the gland appears to me to be objectionable, 
especially as it seldom happens that the healing of 
the wound cannot be obtained by other treatment 
as readily as by excision of the fungus. The same 



CHRONIC ORCHITIS. 345 

objection as that made to excision applies to the 
practice resorted to by some surgeons of tying a 
ligature tightly round the base of the projecting 
tumour, in order to produce strangulation and the 
death of the part ; a plan of treating these cases 
which is certainly more tedious than the knife. 
The following is the method which I usually adopt, 
and I think it will generally be found to succeed in 
these cases : — The patient is directed to keep in 
bed ; and if there is any tenderness or pain in the 
testis, to take four or five grains of blue pill 
night and morning, until all symptoms of existing 
inflammatory action are removed. A piece of lint 
of sufficient size to cover the sore, having been 
dipped in a strong solution of the nitrate of silver 
in the proportion of five grains to the drachm, is 
placed on the part. One or two compresses of 
lint are applied over this, and tolerably firm com- 
pression is then made by several strips of adhesive 
plaister, and the whole is secured by a bandage. 
This is to be repeated daily ; mjid as the protrusion 
recedes the scrotum is drawn over it, and the edges 
of the wound are gradually approximated by narrow 
strips of plaister. Under this treatment cicatriz- 
ation takes place, and the testis gradually resumes 
its place in the scrotum, but remains firmly adher- 
ent to the new skin. In cases where there is no 
occasion for the exhibition of mercury^ or after its 
discontinuance, if the general health be impaired, 
the sulphate of quinine, iodine, steel medicines, or 
bark and soda, may be combined with the local 
remedies. Sir B. Brodie recommends the following 

44 



346 CHRONIC ORCHITIS. 



4 



treatment : — Let the patient be kept in bed in the 
horizontal posture ; give him mercury internally ; 
sprinkle the surface of the fungus every day with 
very finely powdered and levigated nitric-oxide of 
mercury, and over this apply some simple dressing. 
What with the application of the nitric-oxide of 
mercury to the part, and what with the mercury 
administered internally or by inunction, in the 
course of a short time the surface of the fungus 
becomes covered with red healthy granulations. 
As soon as this takes place the application of the 
nitric-oxide of mercury may be left off, and a weak 
solution of sulphate of copper in camphor mixture 
may be used as a dressing. A grain of the former 
may be dissolved in an ounce of the latter, and a 
piece of lint dipped in it may be laid on the fungus 
and changed night and morning, a little simple 
dressing being applied over the whole merely to 
keep the parts moist.^ There are many other 
escharotic applications which will answer the pur- 
pose of checking the growth of the granulations 
and causing their disappearance. Equal parts of 
powdered savine and the sulphate of copper, 
sprinkled on the parts, will be found to answer 
very well, acting partly by producing a slough, 
and partly by promoting absorption. 

* Medical Gazette, vol. xiii. p. 222. 



SYPHILITIC ORCHITIS. 347 



SECTION in. 



SYPHILITIC ORCHITIS. 



In persons affected with secondary syphilis, the 
testicles are liable to undergo a chronic morbid 
enlargement, which is known by the term venereal 
inflammation, it being supposed to be one of the 
sequelae or constitutional effects of the syphilitic 
poison. Though this affection of the testis is not 
an ordinary symptom of secondary syphilis, it is far 
from being rare : when present it is usually accom- 
panied with a pustular or scaly eruption of a vene- 
real character, with periosteal inflammation, and 
not unfrequently with iritis. The symptoms of 
this affection closely resemble those of the chronic 
form of inflammation described in the preceding 
section; indeed the local symptoms of venereal 
orchitis only differ from those of chronic inflam- 
mation of the gland, in the testis becoming occasion- 
ally more tumid and painful during the evening 
exacerbation, or in the occurrence in some cases of 
nocturnal lumbar pains. The enlargement takes 
place slowly and in the same manner, is accom- 
panied with the same dull pain and sense of weight, 
and the disease maintains the same indolent cha- 
racter throughout its entire course, as in chronic 
orchitis. It commonly commences in the body of 
the gland, and rarely terminates in suppuration, or 
in the production of a hernial fungus. Sir A. Cooper 
thinks that, in the majority of cases, the disease 



348 SYPHILITIC ORCHITIS. 

attacks both testicles.* The eight examples re- 
corded in his work do not, however, bear out this 
remark ; for in only two of them does it appear 
that both organs were attacked. According to my 
observation, the disease is more commonly confined 
to a single gland, though it occasionally affects 
both ; and this also appears to be the opinion of 
Ricord.t Sir A. Cooper has had no opportunity 
of dissecting a testis in this state ; nor have I. Sir 
B. Brodie mentions one instance in which he ex- 
amined the venereal testicle, and found the morbid 
appearances to correspond with those observed in 
chronic inflammation.^ 

Syphilitic inflammation of the testis should be 
treated for the most part on the same principles as 
ordinary chronic orchitis. The striking efficacy of 
mercury in this affection has been already explained : 
in the venereal form of orchitis this remedy is also 
most generally required for the disease of the testis, 
as well as for the relief of the other syphilitic symp- 
toms ; and it will commonly be found necessary to 
continue its use, so as to keep up its influence on 
the system for a longer period than in treating 
simple cases of chronic orchitis. Syphilitic inflam- 
mation of the testis may, however, be cured without 
mercury ; and in cases where the constitutional 
debility has been such as to render its exhibition 
unsafe and injurious, I have seen the inflammatory 
enlargement of the gland completely subdued and 

* Lib. cit. p. 105. 

f Traite Pratique des Maladies Veneriennes, p. 640, 

I Medical Gazette, vol. xiii. p. 379. 



TUBERCULAR DISEASE OF THE TESTIS. 349 

the health improved by local depletion, counter- 
irritation, and rest, combined with the decoction of 
sarsaparilla and the iodide of potassium, and other 
remedies adapted for the relief of the constitutional 
symptoms. Sir B. Brodie has recorded an instruc- 
tive case, in which the testis enlarged and suppu- 
rated whilst the constitution was suffering from the 
effects of syphilis and the continued use of mercury. 
The patient was ordered to take sarsaparilla ; and 
in six weeks the testis diminished and the abscess 
healed."^ It should be borne in mind, therefore, that 
although in the majority of cases of syphilitic or- 
chitis mercury is the proper remedy, there are others 
in which it is productive of no benefit, or actually 
injurious, the system being unfitted for the use of 
this remedy, or already suffering from the combined 
effects of the syphilitic poison and mercurial action. 
In many instances, when large doses of mercury 
cannot be safely exhibited, advantage may be ob- 
tained from giving sarsaparilla with the sixteenth 
of a grain of the hydrargyri hichloridum, or the 
sixth of a grain of the hydrargyri iodidum. 



CHAPTER VII. 

TUBERCULAR DISEASE OF THE TESTIS. 

The testis is sometimes the seat of tubercular 
disease. This deposit is commonly met with in 

* London Medical and Physical Journal, vol. Ivi. p. 311. 



350 



TUBERCULAR DISEASE OF THE TESTIS. 



the crude state, forming a yellow caseous sub- 
stance, similar to the tubercular matter occurring 
in the lymphatic glands. It is sometimes developed 
in a single mass ; at other times several distinct 
depositions are formed in different parts of the 
organ ; in both cases at the expense of its glandular 
structure, which becomes atrophied as the disease 
advances. The disease also attacks the epididymis, 
which is, indeed, more frequently 
affected than the body of the testis. 
I have examined many testes at- 
tacked with strumous disease. In 
a specimen given me by Mr. R. 
Robinson of Peckham, which was 
removed from a man who died 
from the same disease in the lungs 
(see figure), the whole of the epi- 
didymis was observed to be occu- 
pied by tubercular matter, with 
scarcely any trace of tubuli ; whilst the body of 
the gland, though small, remained perfectly sound 
and unaffected. In some cases 
two, three, px m^ore distinct 
tubercular deposits were found 
in the testis and epididymis, 
separated by portions of healthy 
gland. This was the case in two 
testes which I removed from a 
middle-aged man who died of 
phthisis. They were injected, 
and a section of one of them is 
represented in the adjoining wood-cut. In several 





TUBERCULAR DISEASE OF THE TESTIS. 351 

instances these isolated masses appeared to be con- 
tained in cysts formed by the processes from the 
tunica albuginea, which separate and support the 
lobules. Sometimes the separate deposits seemed 
to be coalescing and joining together, so as to form 
one continuous mass ; and I have found a single 
mass of tubercular matter surrounded by the glan- 
dular structure expanded into a thin layer. In 
another specimen the whole testis was occupied by 
a homogeneous cheesy mass, without any trace re- 
maining of the original structure of the gland. In 
some cases in which the disease was thus advanced 
there was very little increase in the size of the tes- 
tis ; it only felt heavier and harder than when in the 
natural state. In others, again, there was either a 
general uniform enlargement, or an irregular swell- 
ing at some part, more commonly at the head of 
the epididymis. Some of these testes, in which the 
disease w^as not much advanced, when injected made 
beautiful preparations, the yellow inorganic tuber- 
cular matter contrasting in a marked degree with 
the vermilion hue of the intervening sound portions 
of the organ. On several occasions I found a small 
quantity of serum in the tunica vaginalis, with par- 
tial adhesions and depositions of lymph. In a more 
advanced stage of this disease the characteristic 
deposit becomes softened down and converted into 
a yellow pultaceous substance, evidently tubercular 
matter mixed with pus. The abscess extends to the 
scrotum ; and after it has burst and the matter has 
escaped externally, cavities and sinuses are left 
which may be said to resemble the tubercular cavi- 



352 TUBERCULAR DISEASE OF THE TESTIS. 

ties in the lungs. The course of the affection, 
however, in the testis, more nearly resembles the 
changes which ensue in tubercular disease of the 
absorbent glands. 

It has not been very clearly made out whether 
the tubercular matter is originally formed in the 
cellular tissue connecting the tubuli, or in the tubuli 
themselves. I have certainly seen this deposit in 
the vas deferens near the testis, and in the interior 
of the ducts forming the epididymis ; and Mr. Busk 
of the Dreadnought Hospital once showed me a 
preparation of scrofulous disease of the testis, in 
which the duct of the epididymis could be distinctly 
seen dilated and filled with this matter. Dr. Cars- 
well, in his Pathological Anatomy, has also given 
a representation of a testis from a young man who 
died of phthisis, containing a multitude of pale yel- 
low-coloured granular bodies of various sizes, which 
he says were obviously formed by the accumulation 
of tuberculous matter in the tubuli seminiferi. The 
epididymis was as thick as the little finger, and its 
convoluted ducts were obviously filled with a similar 
deposit. I believe that tubercular matter is de- 
posited in both situations, within as well as between 
the tubuli. 

It is a question as yet undetermined whether 
tubercular matter once deposited in the testis is 
ever got rid of without inflammation, suppuration, 
and the discharge of the morbid product through 
an ulcerated opening. We sometimes meet with 
cases of disease of the testis, the indolent character 
of which and the marked scrofulous diathesis of 



TUBERCULAR DISEASE OF THE TESTIS. 353 

the patient would favour the presumption that the 
gland was the seat of tubercular formation ; and 
yet under appropriate treatment, or even sponta- 
neously, the induration or enlargement subsides, 
and all evidence of disease disappears. My friend 
Mr. R. Robinson had a patient who died of tu- 
bercular disease in various parts of the body, 
whose testis during life, after having acquired a 
considerable magnitude, slowly diminished to its 
natural size. I am not aware that any dissections 
have been made bearing upon this point. In 
some of the above cases the enlargement was pro- 
bably owing in a great measure to the effusion of 
fibrine or albuminous serum in the tunica vagi- 
nalis, consequent upon the inflammation with which 
this disease is often attended ; which deposits, as 
the inflammation subsided, became absorbed, the 
tubercular matter being left but little changed, and 
the testis itself unaltered in size. Laennec con- 
sidered the cretaceous matter found in the lungs as 
an indication of the cure of phthisis ; an opinion 
which appears to be confirmed by the researches of 
Dr. Carswell and others. A cretaceous matter is 
sometimes found in the testis, but more commonly 
in the epididymis (the most frequent seat of tuber- 
cular deposit,) which is exactly similar to the dry, 
putty-looking, chalky matter observed in the lungs 
and bronchial glands. I think it highly probable 
that in some of these cases the gland had, at some 
former period, been the seat of tubercular deposit ; 
but the circumstances under which this earthy 
matter has hitherto been found in the testis were 

45 



354 



TUBERCULAR DISEASE OF THE TESTIS. 




such that I was unable to make any satisfactory 
inquiries on the subject. A 
good specimen of this cretaceous 
matter in the epididymis, from 
the collection of the late Sir A. 
Cooper, is represented in the 
annexed wood-cut. The epi- 
didymis is enlarged, and con- 
tains three separate deposits of 
this matter, whilst the body of 
the testis is perfectly sound. 

Tubercular matter, though 
sometimes formed in the testis 
in the earlier periods of life, 
does not usually occur till after the developement 
of the organ at puberty. We have very little infor- 
mation respecting the relative frequency of this 
deposit in the testis, as compared with other organs. 
In Laennec's table the epididymis is placed in the 
order of frequency before the body of the testis, 
which accords with general observation. In the 
tables of Louis, Lombard, and Papavoine, no men- 
tion is made of the testis. In many instances only 
one testis is attacked ; but not unfrequently both 
glands are affected simultaneously, or one shortly 
after the other. 

The occurrence of this disease in the testis must, 
no doubt, be viewed as one of the manifestations of 
the peculiar morbid state of constitution commonly 
known by the term scrofula. It appears, however, 
that a weak condition of the organ, or an impaired 
organization consequent upon previous disease, 



TUBERCULAR DISEASE OF THE TESTIS. 355 

tends greatly to favour the developement of tubercle 
in this part. Thus, in two cases of phthisis in 
which I met with it, the patients w^ere both affected 
with obstinate strictures, and had suifered from 
consecutive orchitis in early life. 

Symptoms. — The disease commences insidiously, 
and is indolent in its progress. The patient's atten- 
tion is usually first attracted by a slight uneasiness 
in some part of the gland, generally the epididymis, 
which on examination is found to be somewhat 
enlarged, prominent, and hardened. Sometimes 
the whole organ feels slightly enlarged and in- 
durated, though it more frequently forms a tumour 
with an unequal and irregular surface. The state 
of the testis, however, is often masked by small 
local effusions of fluid in the tunica vaginalis, the 
surfaces of this membrane being partially adherent. 
Very little pain is experienced in the part, and 
there is but slight tenderness on pressure. After 
the disease has lasted for some time, many months 
or even a year and more, making little progress, 
and often remaining stationary, one of the promi- 
nences begins to increase, so as to be observed 
externally, and to feel painful and tender ; the skin 
over it becomes adherent, changes to a livid hue, 
ulcerates and bursts, giving vent to a soft caseous 
matter mixed with pus. This is followed by the 
formation of a fistulous sinus, which discharges a 
scanty thin serous pus, mixed with particles of 
tubercular matter, and often with semen, particu- 
larly after venereal excitement. Similar changes 
may take place in other parts of the testis, occa- 



356 TUBERCULAR DISEASE OF THE TESTIS. 

sioning two or more sinuses leading to the interior 
of the gland. These sinuses sometimes communi- 
cate, and they may continue open and discharging 
for a great length of time. After the deposit has 
ail come away, if the original disease be arrested, 
and no more tubercular matter formed, reparative 
changes sometimes take place, the discharge ceases, 
the fistulsg close up, leaving the organ m^ore or less 
diminished in size or entirely wasted, according to 
the extent to which it had been disorganized by 
the tubercular deposit. The bursting of the ab- 
scess and escape of the tubercular matter are 
sometimes followed by a hernial protrusion of the 
testis, as after chronic inflammation of the gland. 
Strumous disease of the testis is not often seen in 
the suppurative stage in children, or before the age 
of puberty, — A little boy aged B.ve years, with fair 
complexion, bright eyes, and florid cheeks, was 
brought to me at the hospital in March, 1842, on 
account of an affection of the left testis. This 
gland was three or four times the size of the right ; 
of an oval form, with an uneven surface, so as to 
feel nodular ; extremely indurated, indeed almost 
as hard as cartilage ; and was nearly insensible to 
pressure. 1 ordered small doses of the hydrarg. 
cum cretu, and the camphorated mercurial ointment 
to the part. As the swelling remained l3ut little 
changed at the end of three weeks, I prescribed the 
decoction of bark, with three grains of the iodide of 
potassium, to be taken three tim.es a day, and some 
iodine ointment to be applied to the enlarged testis. 
In May the skin became adherent to the lower part 



TUBERCULAR DISEASE OF THE TESTIS. 337 

of the testis ; an abscess formed, and about the 
middle of June burst, and discharged some caseous 
matter and thin pus, and left a fistulous opening. 
The health began to fail, which induced me to 
substitute some steel medicine for the iodide of 
potassium. The mother became phthisical and too 
ill to bring the boy, and I saw nothing more of 
him till the father brought him to see me in the 
following November ; when I found the fistula 
closed, the testis a good deal reduced in size, but still 
hard and nodular, and adherent to the lower part of 
the scrotum. The boy's health was much improved. 
Another small abscess subsequently formed and 
burst as before, since which I have lost sight of the 
patient. Mr. Lloyd relates the following case. — 
A child three years and a half old was brought to 
him with the right testicle affected. The whole 
scrotum was distended with matter, and appeared 
like a scrofulous abscess in any other part of the 
body, and the skin was so thin that you might see 
the matter through it. A poultice was applied, 
and in a few days the abscess burst ; and the aper- 
ture soon enlarged so much that full half of the 
gland projected through the scrotum, and was 
converted into a mass of yellow scrofulous matter, 
which a few days after separated, leaving the re- 
mainder of the gland enlarged and hardened. This 
was, however, rapidly diminishing, and seemed 
likely to entirely waste away."^ 

This disease is frequently connected with scro- 

'^ Treatise on Scrofula, p. 93. 



358 TUBERCULAR DISEASE OF THE TESTIS. 

fulous affections of other parts/^ The patient is 
either phthisical, or subject to strumous swellings 
of the lymphatic or mesenteric glands ; or affected 
with disease of the spine, hip, knee, or some other 
articulation, and manifests the ordinary charac- 
teristics of a scrofulous constitution ; so that in 
many cases, certainly in the majority of those 
which have come under my notice, the affection of 
the testis was of secondary importance to disease 
existing in other organs, and to the morbid state 
of the system generally. The constitution, also, is 
very slightly affected by, or sympathizes very little 
with, the morbid changes going on in the testis. 

Diagnosis. — Tubercular disease of the testis 
may be mistaken for chronic, inflammatory, and 
malignant enlargements of the gland. Writers on 
the diseases of the testis often confound the former 
of these affections with the tubercular disease, being 
misled by the indolent nature of the swelling and the 
yellow appearance of the morbid deposit in chronic 
orchitis. The strumous disease differs, however, from 
the chronic inflammatory swelling in being more 
indolent ; in making even slower progress, and 
being attended with still less pain and inconve- 
nience ; in the irregular surface and smaller size of 
the swelling ; and, when the epididymis is attacked, 
in the globus major being the part principally 
affected, instead of the lower part, which is usually 
first enlarged in chronic inflammation. The di- 



* When the testes become tubercular, the vesiculse seminales are 
also very liable to be affected with the sanio disease. 



TUBERCULAR DISEASE OF THE TESTIS. 359 

agnosis, however, is not always easy, as in both 
cases the character of the swelling is often masked 
by the effusion of fluid in the tunica vaginalis. 
The disease may be distinguished from malignant 
enlargements of the organ by the smaller size, un- 
even surface, and more indurated nature of the 
swelling, and by its very chronic progress. In all 
cases the judgment of the surgeon will be ma- 
terially assisted by his noting the general characters 
of the constitution, and whether there is any con- 
comitant affection of other parts. 

Treatment, — From what has been remarked in 
reference to this disease, it will naturally be inferred 
that the remedies of most consequence are those 
calculated to correct the morbid state of constitu- 
tion which predisposes to local scrofulous deposit. 
The patient should reside in a pure air in the 
country, and, if possible, by the sea side, for many 
months. He should take gentle exercise. The 
diet should be nutritious, consisting of a due pro- 
portion of animal and vegetable food ; and stimu- 
lating viands and drinks must be strictly prohibited. 
Malt liquors, as light pale ale, or a glass or two of 
wine, may, however, be taken in many cases with 
advantage. Medicines which tend to improve the 
appetite and give tone to the digestive organs are 
to be exhibited. Steel medicines, as the vinum 
ferri, the citrate or sesquioxide of iron, the decoc- 
tion of bark with the sesquicarbonate of soda, the 
sulphate of quinine with sulphuric acid, the infu- 
sion of gentian or decoction of sarsaparilla with the 
liquor potassae long continued, are all more or less 



360 TUBERCULAR DISEASE OF THE TESTIS. 

serviceable, and may be occasionally suspended or 
varied, one being substituted for the other. There 
is, however, no remedy which exerts a more bene- 
ficial influence in this affection than iodine, or the 
iodide of potassium. I usually prescribe for the 
adult the decoctum sarzcE, with five or six grains 
of the iodide of potassium, to be taken three times 
a day for some length of time, directing it to be 
discontinued for two or three days or a week, and 
again resorted to. When the patient is in a good 
air the constitution and local symptoms often mend 
in a remarkable degree under this treatment. Mer- 
cury, which is so eminently beneficial in chronic 
inflammation of the testis, is seldom of service in 
this disease : indeed, as in strumous affections ge- 
nerally, its influence is usually prejudicial. Small 
alterative doses, as four grains of Plummer's pill, 
taken at night, or the sixteenth of a grain of the 
bichloride of mercury given in the decoctum sarzae 
twice 6y thrice in the day, have sometimes been 
resorted to with advantage ; but my experience 
generally leads me to think unfavourably of the 
use of mercury in any form in this affection. 

When inflammatory symptoms exist they must 
be combated by the application of leeches, cooling 
lotions, and rest in the recumbent position. Anti- 
phlogistic measures are not often necessary. In all 
cases the gland must be supported. In the indolent 
stage of the disease the local treatment consists in 
painting the scrotum with the tincture of iodine 
every alternate day, or oftener ; or the Ung. lodinii 
Comp., mixed with an equal proportion of lard, may 



CARCmOMA OF THE TESTIS. 361 

be rubbed on the part. Strapping the testis with 
the Emplast. Atnmoniaci cum Hydrargyro has, in 
several instances, appeared to promote the disap- 
pearance of the swelling and induration. When 
suppuration ensues the part may be poulticed; and 
after the abscess has burst the orifices of the sinuses 
must be kept well open, to allow of the free escape 
of the morbid deposit. In some cases in which the 
testis is completely disorganized and useless, and 
when the sinuses prove very obstinate and trouble- 
some, castration may be necessary ; but this opera- 
tion is seldom required, and it should never be per- 
formed whilst there is any evidence of disease in 
the lungs, or organic affection elsewhere. 



CHAPTER VIII. 

CARCINOMA OF THE TESTIS. 



The testis, like other glandular organs, is liable to 
carcinomatous disease. A schirrous testis was for- 
merly spoken of as a common affection ; but then 
all chronic enlargements possessing much induration 
were usually designated schirrus. Surgeons have 
since learned to discriminate the enlargements con- 
sequent on inflammation from those produced by 
malignant disease : the latter are now known to be 
comparatively rare. Carcinoma is met with in the 
testis under the four forms of Schirrus, Enccpha- 
loid, Colloid, and Melanosis. 

46 



362 SCHIRRUS OF THE TESTIS. 

SECTION I. 

SCHIRRUS OF THE TESTIS. 



n 



Schirrus never occurs in the testis in the dense 
form which it commonly assumes in the breast. 
Sir A. Cooper, however, describes^ a schirrous dis- 
ease of the testis, in which a hard white mass in 
lobes or tubercles, and possessing little vascularity, 
is found in the place of the tubuli seminiferi. This 
is sometimes interspersed with small portions of 
cartilage or bone. The epididymis contains a simi- 
lar firm fibrous mass ; and the spermatic cord is 
enlarged, and has small white tubercles in it. The 
glands of the abdomen become converted into a 
white solid texture, very unlike that of the fungoid 
disease. The disease appears, from this description, 
to correspond with that form of schirrus described 
by Miiller under the name of carcinoma reticulare, 
the consistency of which ranges between that of 
ordinary schirrus and encephaloid, and which con- 
sists fundamentally of a gray globular matter, 
embedded in meshes formed of fibrous fasciculi, and 
has a greater tendency to lobular arrangement than 
simple schirrus. I have not witnessed any case of 
this disease, which must be exceedingly rare. 

Symptoms. — Sir A. Cooper describes this kind 
of cancer as beginning in an enlargement of the 
body of the testis, accompanied with great weight 

* Lib. cit. p, 150. 



SCHIRRUS OF THE TESTIS. 3GS 

and severe occasional pain ; never becoming soft 
nor so large as the encephaloid cancer, nor pro- 
ducing a fungoid or very vascular bleeding surface, 
but feeling tubercular, irregular, and excessively 
hard. The pain extends to the loins ; the spermatic 
cord becomes enlarged, hardened, and tuberculated ; 
and a smaller tumour than that of the fungoid 
disease forms in the abdomen. Some water is se- 
creted into the tunica vaginalis ; the cellular mem- 
brane of the leg and thigh of the diseased side 
becomes dropsical, and afterwards the other leg is 
similarly aifected. Ulceration he had seen occur 
once : the testis gradually wasted under it ; the 
glands of the groin became diseased, and the man 
after some months died. But this state rarely 
happens ; for generally, without ulceration, the 
patient's countenance becomes sallow, and he sinks 
under impaired digestion, pain and tumour in the 
abdomen, and an irregular state of the bowels, 
which are frequently accompanied with ascites. 

Diagnosis. — This form of cancer is characterized 
by its slow progress and great hardness during the 
whole continuance of the disease, and also by its 
weight and irregular and tuberculated feel. It 
does not become soft like encephaloid cancer, and 
it occurs less in different parts of the body at the 
same time, and is slower in proceeding to its fatal 
termination. 

Treatment. — There is no other remedy for this 
disease but castration, which must not be delayed 
so as to endanger a production of the disease in the 
spermatic cord, or the growth of a tumour in the 



364 ENCEPHALOID CANCER OF THE TESTIS. 

abdomen. Sir A. Cooper relates the case of a man 
aged 44, whose testicle was attacked with this form 
of cancer. The gland was removed in Guy's Hos- 
pital nine months after its first appearance, and the 
wound healed ; but the thigh and leg, which were 
oedematous at the time of the operation, remained 
swollen, and he died a month after his return home. 



SECTION 11. 

ENCEPHALOID CANCER OF THE TESTIS. 

This is by far the most frequent disease of a ma- 
lignant character to which the testis is liable. It 
is called by different writers pulpy testis, medullary 
sarcoma, soft cancer, fungoid disease, or fungus 
hcematodes, I have adopted the term encephaloid 
given to this cancerous growth by Laennec, as it 
is the one now most generally employed by patho- 
logists. 

Encephaloid cancer, when first observed in the 
testis, is found in one or two masses amongst the 
tubuli, which gradually become destroyed as the 
morbid deposit accumulates. In some instances, 
examined at the commencement of the disease, the 
glandular structure has been found expanded around 
a solitary deposit in the centre of the organ. The 
matter is very rarely infiltrated. The testis at 
this early period is extremely firm and hard, owing 
not to the solid nature of the substance effused, but 
to the excessive distension of the unyielding tunica 
albuginea by the morbid growth within. The 



ENCErHALOID CANCER OF THE TESTIS. 365 

glandular structure soon entirely disappears, the 
whole organ being occupied by the new growth in- 
termixed with, and sustained by, the septa and 
fibrous processes from the mediastinum and tunica 
albuginea. At this stage the tunica vaginalis is 
often distended with serum ; not, however, in any 
considerable quantity. The effusion is caused by 
inflammation, excited by the presence of the en- 
cephaloid matter within the testis: the inflamma- 
tion sometimes produces adhesion, and partial or 
complete obliteration of the cavity of the tunica va- 
ginalis. The tunica albuginea next gives way, and 
a portion of the morbid growth protrudes, forming 
a mass projecting from the body of the gland ; this 
sometimes occurs in more places than one. The 
epididymis remains for some time unaflected ; but 
as the disease increases this part likewise becomes 
implicated and destroyed. In a case I recently ex- 
amined, the canals at the head of the epididymis 
(the only part of the gland not destroyed) were 
distinctly seen filled with a white matter, which on 
examination in the microscope was found to be car- 
cinomatous. The scrotum in a short time becomes 
fully distended by the diseased mass, which pre- 
sents the well-known appearance of encephaloid 
cancer :* viz. a homogeneous substance of the con- 



* I do not think it necessary to give here a detailed account of the 
characters of encephaloid cancer and its mode of developement, my 
object being to describe the general appearances and modifications 
which it presents in the testis. For a more minute description of this 
morbid deposit, I must refer the reader to works on Morbid Anatomy, 
but especially to the admirable article on cancer by Professor Walshe, 
in the Cyclopaedia of Surgery. 



366 ENCEPHALOID CANCER OF THE TESTIS. 

sistence of brain, and easily broken down with the 
fingers, of an opaque white colour, and variegated 
with patches of a pinkish hue. It is sometimes 
mixed with small cysts containing serum and yellow 
deposits of lymph resembling that effused in chronic 
orchitis. 

These small depositions of yellow fibrine, occa- 
sionally interspersed amongst the carcinomatous 
matter, I believe to be peculiar to this disease in 
the testis, as I have not observed cancer it in of 
other parts. When the scrotum gives way, the 
morbid growth projects as a bleeding fungus. The 
enlarged mass then becomes less firm, and its con- 
sistence varies very much in different parts, the 
morbid matter being in some a mere pulp, or resem- 
bling a creamy fluid. It is interspersed with round 
or irregular patches of dark-looking coagula, and 
when incised often presents in different places dark 
minute spots of various sizes, produced by coagu- 
lation of blood in the vascular network, usually 
mixed up with the morbid deposit. On macerating 
these tumours, or on pouring a stream of water on 
them for some time, a granular substance, the can- 
cerous matter, is washed away, leaving behind a 
filamentous shreddy tissue or meshes of a delicate 
cellular texture, which may often be found con- 
nected to a denser fibrous substance, the remains 
of the tunica albuginea. The spermatic cord is 
often invaded by a similar substance ; and in an ad- 
vanced stage of the complaint large bodies of the 
same kind, originating in disease of the lumbar 
glands, are found on the sides of the vertebrae, 



ENCEPHALOID CANCER OF THE TESTIS. 367 

reaching as high up as the diaphragm. The ab- 
dominal aorta and ascending vena cava become 
surrounded by them, and are often displaced or 
compressed. I have known the circulation through 
the vena cava completely obstructed by the pres- 
sure. This vessel has also been found filled with, 
and obliterated by, encephaloid matter. The 
kidneys are sometimes encroached upon by the 
disease. The spine too may be implicated, the 
bones of the lumbar vertebrae being more or less 
destroyed by the progress of the morbid growth, 
which, indeed, spares no parts or textures in its 
progress. The glands in the groin of the side 
corresponding to the diseased testis escape contami- 
nation more frequently than those in the loins ; still 
they often become affected. It has been said that 
they do not enlarge until the disease has reached 
the scrotum. Such, however, is not always the 
case ; for I have seen them affected before any 
appearance of disease in this part. Mr. Abernethy 
describes a case in which the glands in both groins 
became so enlarged that the skin over them ulcer- 
ated, without the scrotum being involved.^ As the 
lumbar glands enlarge, the peritoneum covering 
them and the various viscera are pushed forwards, 
and there is often serous effusion in the cavity of 
the abdomen. In some instances the mesenteric 
glands are diseased, and carcinomatous tubercles 
are found dispersed through the liver. Masses of 
a similar kind are sometimes also found in the 

* Observations on Tumours, p. 52. 



368 ENCEPHALOID CANCER OF THE TESTIS. 

lungs, the thoracic cavities being occupied by serous 
effusion. The carcinomatous matter is often de- 
posited in such abundance as to form a tumour of 
very considerable size ; indeed, there is no other 
disease of the testis which occasions solid enlarge- 
ments of so great a magnitude as encephaloid 
cancer. M. P. Boyer removed, at the Hopital St. 
Louis in Paris, a testis converted into an encepha- 
loid tumour v^^hich weighed more than nine pounds.* 
The vessels of the cord undergo great enlargement 
in this disease ; in one case which I examined the 
spermatic artery was found as large as the radial 
artery at the wrist. 

Encephaloid cancer of the testis occurs at all 
periods of life : no age, indeed, can be said to be 
exempt from it. Mr. Cline operated for this affec- 
tion on a boy ^ve years of age ; the disease unfor- 
tunately returned. Sir W. Blizard extirpated the 
testis of a child two years and a half old, on account 
of a carcinomatous tumour of the organ, measuring 
an inch and a half in its greatest diameter, and 
one inch in its smallest. The diseased gland is pre- 
served in the museum of the College of Surgeons. 
The late Mr. H. Earle published an account of a case 
in which the disease attacked the testis of a child 
very little more than a year old. The part was re- 
moved, but in a few months he died of the same dis- 
ease in the brain and other parts.t Mr. LangstafF 
preserved the carcinomatous testis of a child, which 
began to enlarge when he was only ten months old. 

* Revue Medicale, Nov. 1839. 

t Medico-Chirurgical Transactions, p. 59. 



ENCEPHALOID CANCER OF THE TESTIS. 369 

It increased rapidly, and in the course of two 
months acquired the magnitude and figure of a 
hen's egg. Castration was performed, but the 
patient lived only six months afterwards. The 
lumbar glands, lungs and dura mater were found 
affected with the same disease."^ The disease, 
however, more commonly occurs in the middle 
period of life, or between the ages of twenty and 
thirty ; but I have met with it at a much more 
advanced age. A patient lately died in the London 
Hospital of carcinoma of the testis at the age 
of sixty. Mr. Byles of Spitalfields sent to my 
house a pauper aged sixty-four, whose left testis 
formed a tumour the size of a large orange, 
which had been coming about six months. The 
glands in the groin were enlarged and the left 
leg was cedematous. The disease afterwards made 
rapid progress. The testis and swellings in the 
groin increased to a great size : the scrotum ul- 
cerated, and a bleeding and sloughing fungus pro- 
truded. The man died about two months after I 
first saw him. It very rarely happens that both 
testes become affected ; and in this case the right, 
though completely enveloped in the morbid deposit, 
was found after death quite sound. 

Symptoms. — The disease commences in an en- 
largement, with considerable induration of the body 
of the testis, which preserves its oval form and even 
surface. The enlargement is attended with slight 
tenderness, a dull pain, and occasionally with a 

* Catalogue of Preparations, p. 372. 
47 



370 ENCEPHALOID CANCER OF THE TESTIS. 

little effusion into the tunica vaginalis. The growth 
of the morbid deposit varies, and is very unequal. 
It is sometimes very slow, the disease making but 
little progress in several months ; at other times it 
increases rapidly. Its growth is liable to be acce- 
lerated by a slight blow or exercise. As the gland 
enlarges it becomes uneven, and feels irregular and 
tuberculated. It loses, too, its indurated character, 
and becomes soft, but more so in one part than in 
another, and acquires an elastic feel. As the disease 
thus advances the pain increases, but still amounts 
to little more than a dull sense of weight extending 
up to the loins. The spermatic cord becomes thick 
and full, owing to enlargement of the various blood- 
vessels. The scrotum is at first unaltered ; but as 
it becomes distended by the increasing size of the 
tumour, its veins are obstructed, and appear swollen 
and varicose. By this period the glands in the 
lumbar region usually become diseased and en- 
larged, and the lower extremity of the side affected 
swells from oedema. The surgeon may in a short 
time distinguish the swellings on the side of the 
spine by making pressure on the abdomen. The 
pains in the loins and abdomen soon become con- 
stant, and the patient's sufferings are altogether 
much increased. The general health, which was at 
first but little affected, now exhibits a material al- 
teration. The patient loses flesh and strength, his 
countenance assumes a peculiar sallow hue, his 
tongue is furred, and his appetite and digestion are 
more or less impaired. As the enlargement goes 
on the scrotum becomes adherent to the tumour in 



ENCEPHALOID CANCER OF THE TESTIS. 371 

one or more places ; then ulcerates, and allows the 
protrusion of the morbid mass, which projects as an 
open bleeding fungus, discharging a thin fluid mixed 
with blood, and having a disagreeable faint odour. 
The disease then makes very rapid progress ; the 
fungus spreads ; sloughs form on its surface ; coagula 
separate ; bleeding repeatedly occurs ; and the pa- 
tient at length sinks, dying from the drain on the 
system, or from the interference of the morbid de- 
posit in the functions of the important internal 
organs. The diseased testis sometimes attains a 
very large size without the appearance of a bleed- 
ing fungus, as the scrotum admits of great distension 
before ulceration ensues. Mr. Wardrop remarks, in- 
deed, that in no case has he even been able to learn 
that the integuments have given way, and a fungus 
grown from the diseased testicle ; and Sir B. Brodie 
likewise states that it has not fallen in his way to 
observe a tumour in this advanced stage."^ At 
page 369 I have briefly related the particulars of a 
case that came under my notice, in which the dis- 
ease extended so as to produce a bleeding fungus ; 
but as the testis is usually removed before the 
disease reaches this point, it is rarely that an op- 
portunity is afforded to the surgeon of witnessing it. 
Besides, as the scrotum admits of very considerable 
distension without ulceration being induced, the 
patient's life may be destroyed by a similar aifection 
of the internal organs before the skin gives way. 
In the case of the old man who lately died in the 

* Lond. Med. Gazette, vol. xiii. p. 408. 



372 ENCEPHALOID CANCER OF THE TESTIS. 

London Hospital to which 1 have referred, life 
was destroyed by internal disease before even the 
tunica albuginea had given way.^ Sir B. Brodie 
has remarked that in many cases the tumour in 
the loins gives the patient no pain, and but little 
inconvenience, while at other times it is attended 
with the most extraordinary suffering. He sup- 
poses this to depend on the accidental circum- 
stance of it sometimes pressing upon nerves, and 
in other cases lying clear of them. A gentleman 
with whom he was acquainted many years ago 
had this disease in the testis, Mr. Cline was con- 
sulted, and he recommended the amputation of 
the testis, and performed the operation. A year 
afterwards the patient became weak in his lower 
limbs, and at last they became completely paralytic. 
He died ; and on examining the body after death, 
there was found a large tumour in the loins, which 
had affected the vertebrce so as at last to press on 
the medulla spinalis, thus accounting for the para- 
plegia.t Cruveilhier has recorded the case of a 
man aged twenty-seven, whose testis was extirpated 
on account of alveolar cancer. The disease did 
not return in the part, but made its appearance in 
the body of the sixth and seventh cervical vertebrae 
and the posterior extremities of the two first ribs, 
and caused death by pressing on the medulla spi- 
nalis, and producing paralysis of the parts below.J 

* In this case carcinomatous matter was found deposited in the 
muscular substance of the heart, and also in the lungs, 
t Lib. cit. p. 408. 
} Anatomic Pathologique du Corps Humain, liv. v. p. 1. 



ENCEPHALOID CANCER OF THE TESTIS. 373 

Mr. Pott met with a case of carcinoma affecting 
a testis detained in the right groin in a man fifty- 
five years old. There was a large ulcerated sore 
with high callous edges, which discharged an offen- 
sive gleet, at times bled profusely, and was ex- 
tremely painful. After death the lymphatic glands 
about the vertebrae of the loins, and the liver and 
right kidney, were found affected with the same 
disease.* 

Diagnosis. — Encephaloid cancer of the testis 
may be confounded with hydrocele, with hasmato- 
cele, with the cystic disease, and in its early stage 
with chronic orchitis. It differs from hydrocele in 
being of an oval shape ; in its sides being somewhat 
flattened ; in the circumstance that the enlargement 
takes place uniformly, and not from the bottom, as 
in hydrocele ; in the uneven surface of the swelling; 
in the absence of transparency ; and in the greater 
weight of the tumour when balanced in the hand. 
Encephaloid cancer, when handled, gives an indis- 
tinct feeling of fluctuation, which has often proved 
very deceptive, and puzzled the most experienced 
surgeons. By a careful examination, however, the 
difference may generally be detected, as the consist- 
ence and obscure sense of fluctuation vary in dif- 
ferent parts, the tumour being softer in one place 
than in another. A hasmatocele, especially if the 
sac be much thickened, is more difficult to be dis- 
tinguished from this disease than a hydrocele, the 
tumour being heavier and wanting transparency, 

* Works, 4to. edit. p. 357. 



374 ENCEPHALOID CANCER OF THE TESTIS. 

and fluctuation being very obscure or imperceptible ; 
circumstances in which I have stated that the en- 
cephaloid disease differs also from hydrocele. The 
other distinguishing marks mentioned, together 
with a patient inquiry into the history of the case, 
will generally enable the practitioner to distinguish 
these two affections. In a case of difficulty, all 
doubt might be set at rest by a puncture with a 
trocar or lancet. If the swelling should happen 
to prove carcinomatous, there would be a flow of 
blood, and perhaps an escape of a small quantity 
of brain-like matter. But the bleeding would soon 
cease, and the wound being closed by plaister 
would probably heal, and no ill consequences result. 
Encephaloid cancer may very readily be mistaken 
for the cystic disease, before at least the former 
arrives at that stage when no prudent surgeon 
would contemplate an operation. The tumour 
caused by the malignant disease makes more rapid 
and more variable progress, and its surface is less 
even and its consistency less uniform than the 
cystic sarcoma ; but in other respects the characters 
of the swelling in these two diseases are so similar, 
that no certain directions can be given for distin- 
guishing them. The necessity for making the dis- 
tinction is perhaps less, since in both cases no other 
treatment is of service but an operation ; after which 
an examination of the diseased organ will afford the 
surgeon the opportunity of pronouncing an opinion 
as to the security obtained from future disease. 
Very great difficulty is experienced to distinguish- 
ing encephaloid disease in its early stage from the 



ENCEPHALOID CANCER OF THE TESTIS. 375 

enlargement produced by chronic inflammation ; 
and as the success of an operation in cases of this 
malignant disease depends very much upon the 
period at which it is performed, it is of no slight 
importance that the nature of the affection should 
be detected as early as possible. As there are no 
external marks that can be relied on for distin- 
guishing the two diseases, the only course that can 
be adopted is to exhibit mercury so as to make the 
gums slightly sore ; when, if the induration and 
enlargement should happen to depend on chronic 
inflammation, the gland will gradually begin to 
soften and diminish, and if the remedy be perse- 
vered in a little longer will be restored to its natu- 
ral state. If, on the contrary, no change ensue, or 
if the testis continue rather to increase in bulk, it 
may be pretty certainly concluded that the alter- 
ation in structure is of a malignant character, or 
that it results from a disease for which there is no 
remedy but the knife, and we should therefore be 
justified in recommending an operation. 

The following example will serve to illustrate 
some of the difficulties of the diagnosis in these 
cases, and to point out the kind of careful investi- 
gation necessary to enable the surgeon to form a 
correct opinion respecting the nature of the disease. 
— A healthy-looking man, aged thirty-four, married, 
and by trade a carpenter, applied for relief on ac- 
count of a chronic enlargement of his left testis. 
About nine or ten months previously he first per- 
ceived an increase in the size and weight of the 
organ, which occurred without any apparent cause 



376 ENCEPHALOID CA^XER OF THE TESTIS. 

or the receipt of any injury to the part. He con- 
tinued at his occupation, taking little heed of the 
swelling, until at length becoming alarmed by its 
increasing to seven or eight times the size of the 
other testis, and experiencing considerable incon- 
venience from its bulk and weight, he was induced 
to seek surgical assistance. There was a large 
tumour occupying the left side of the scrotum. It 
was of an oval form ; its surface was pretty even, 
except at the upper and front part, which had a 
slight, smooth, and round projection. The skin 
covering the swelling was sound, and not adherent ; 
but the subcutaneous veins were a good deal di- 
lated. The consistence of the swelling generally 
was about that of a hoematocele ; but then it was un- 
equal, being firmer in front than at other parts. On 
seeking for fluctuation, the obscure sensation pro- 
duced was more like the resilience of a soft elastic 
solid than the displacement of a fluid. The small 
projection above, however, communicated a more 
evident feeling of fluid. The weight of the tumour 
was greater than that of a hydrocele, but might be 
about that of a htematocele or a soft solid growth. 
The swelling was not transparent, and had little 
sensibility, firm pressure causing merely a dull 
pain. The testis completely escaped detection : it 
could be distinguished neither by its form or con- 
sistence, nor by the character of the pain usually 
experienced from compression. The spermatic cord 
was full and large, but otherwise natural, and it 
passed to the posterior part of the tumour. The 
lumbar and iliac glands appeared to be free from 



ENCEPHALOID CANCER OF THE TESTIS. 377 

disease. The important internal organs performed 
their functions properly, and there was no indi- 
cation of a morbid state of constitution. Such, 
then, were the characters of the tumour, and the 
symptoms by which it was to be ascertained whether 
the disease was a hydrocele with thickening of the 
investing tunics, a hasmatocele, cystic sarcoma, or 
encephaloid cancer. Against the supposition of a 
hydrocele there was the oval shape, uneven surface, 
greater weight and irregular consistence of the 
tumour, the absence of transparency, and the im- 
possibility of detecting the testis by firm pressure 
at the part where the gland is usually found in 
cases of effusion into the tunica vaginalis. Op- 
posed to the idea of a hsematocele there was not 
only the irregular surface, varying consistence, and 
impossibility of detecting the testis by pressure ; 
but also the mode of growth, the tumour in hsema- 
tocele being of sudden or rapid formation, more 
often occurring from some injury, and when formed 
afterwards remaining little altered for a consider- 
able period : whereas in this case the swelling 
arose spontaneously, took nine or ten months to 
acquire its large size, and still continued to increase. 
It was concluded, then, that the tumour must be 
either cystic sarcoma or encephaloid cancer, its 
mode of formation, shape, size, weight, and general 
consistence, and the state of the cord being such as 
might correspond to either of these two diseases. 
The irregularity in the surface and consistence of 
the swelling, and the large developement of the 
subcutaneous vessels, induced me to incline to the 

48 



378 ENCEPHALOID CANCER OF THE TESTIS. 

opinion that the growth was of a carcinomatous 
character ; and such proved to be its nature when 
the tumour was removed after an exploring punc- 
ture. There was no trace of the glandular struc- 
ture of the testis remaining ; but the epididymis was 
sound, and situated at the upper part of the tumour, 
surrounded by the tunica vaginalis, which con- 
tained about six drachms of serum, and formed the 
indistinctly fluctuating projection observed at this 
part. 

Treatment. — There is no disease of a more dan- 
gerous and fatal tendency than encephaloid cancer. 
No medicine or local treatment of any kind is able 
to arrest its progress, and the only alternative left 
for us to adopt when it attacks the testis is that of 
amputation of the affected organ. Unfortunately 
this resource is exceedingly liable to fail, the disease 
generally reappearing in the lymphatic glands con- 
nected with the testis, in the wound, or in some 
internal organ. Numerous cases in which the dis- 
ease has thus returned have been published by 
various surgeons ; and so unsuccessful has this 
operation proved, that the propriety of having re- 
course to it under any circumstances has been 
strongly called in question. I scarcely know an 
instance of castration having been performed for 
this disease in which the patient has survived for 
any lengthened period. Sir A. Cooper, whose ex- 
perience was very great, has recorded ^\e cases, in 
all of which the disease returned after the operation, 
but not one attended with a successful result ; and 
Sir B. Brodie states that he has known but one 



ENCEPHALOID CANCER OF THE TESTIS. 379 

instance in which there was no recurrence of the 
disease. The patient was a French courier, and 
had the disease in one testicle, which was ampu- 
tated. Three or four years after the operation Sir 
B. Brodie learned that he was going on favourably. 
The operation may, however, have succeeded in 
some few cases which have afterwards been lost 
sight of "^ 

It has been shown, by the recent microscopical 
inquiries of Miiller and others, that the intimate 
texture of carcinoma consists of a mass of nucleated 
cells, very similar to the primary cells of develope- 
ment mef with in healthy tissues, and which seem 
to possess similar independent powers of growth, 
new cells being formed from the nuclei, which, like 
the parent cells, have the property of multiplying 
their kind. There are many reasons for concluding 
that the origin of carcinoma is local — that the dis- 
ease is produced by some local irritating cause, and 
is confined for a time to the part in which it is 
developed ; but, being once formed, it is very prone 
to spread to other parts, owing probably to the 
passage of the cells or cancerous germs into the 
blood. This liability to the formation of secondary 
deposits is greater in certain forms of cancer than 
in others, and also in cancer of certain parts than 
in that of others. Our present experience of car- 
cinomatous disease is sufficient to prove, that in 
some instances a cancerous growth may be removed 

* Much valuable information might be gained, if surgeons would 
endeavour to ascertain and register the results of their operations rof 
this disease. 



380 ENCEPHALOID CANCER OF THE TESTIS. 

before the disease has been communicated to dis- 
tant parts, patients having survived an operation for 
years without the appearance of secondary growths, 
and without experiencing any fresh developement of 
carcinomatous matter, and having died of another 
disease ; that carcinomatous matter is sometimes 
developed in a particular part of the body, and 
produces death by its irritative effects on the con- 
stitution, without being conveyed to or contami- 
nating any other parts, except those immediately 
connected with its original seat ; and that in other 
cases, though the removal of the part primarily 
affected may be too late to eradicate the disease 
from the constitution, it having ceased to be local, 
its developement in other parts previously contami- 
nated may take place so slowly, and make such tardy 
progress, that the extirpation of the cancer from its 
original seat, where it was rapidly advancing, tends 
more or less to prolong the patient's existence. The 
tendency of carcinoma to spread is particularly rife 
in the early period of life, when the powers of growth 
are in active operation, as is evinced by the almost 
constant failure of operations for cancer of the tes- 
tis and of the eye in infants. This tendency seems 
to diminish with age. Thus in advanced life car- 
cinoma makes slower progress, and, if extirpated, is 
by no means so apt to reappear as in early life ; so 
that the prospect of security from a return of the 
disease after an operation, cceteris paribus, increases 
with the age of the patient. Of all the forms of car- 
cinoma, encephaloid cancer is the most prone to 
form secondary growths, and consequently the most 



ENCEPHALOID CANCER OF THE TESTIS. 381 

difficult to eradicate by operation. Nevertheless, 
believing the origin of the disease to be local, I think 
the attempt to remove a malady of so fatal a cha- 
racter well deserves a trial ; and I am therefore by 
no means disposed to agree with those practitioners 
who condemn the extirpation of the testis when 
affected with encephaloid disease, more especially 
as castration is not, under ordinary circumstances, 
an operation dangerous to life. The chance of suc- 
cess may be a poor one ; but it is better that the 
patient should have that chance, poor as it is, in- 
stead of the case being abandoned as hopeless, and 
the sufferer being left to the consequences of an 
early and painful death. But to afford a reason- 
able hope of success, castration should be performed 
at the earliest period possible, in a suspicious case 
as soon as the surgeon can make up his mind that 
the disease, whether carcinomatous or not, is of a 
nature incurable by ordinary remedies; for there 
are few diseases in which a prompt decision is more 
necessary than in this. The operator must of course 
make a very careful examination of the important 
internal organs, especially of the lumbar and in- 
guinal regions and spermatic cord, as an affection 
of these parts would destroy all hope of benefit from 
the operation, and render its performance improper. 
He should also make, just previous to the operation, 
one or two punctures in the tumour, in order to set 
at rest any doubt that might exist in regard to the 
nature of the disease. 



382 CARCINOMA OF THE TUNICA VAGINALIS. 

SECTION III. 

CARCINOMA OF THE TUNICA VAGINALIS. 

Carcinomatous disease has, in some few instances, 
been found to originate from the tunica vaginalis, 
the glandular part of the testis remaining for some 
time unaffected. An important peculiarity in these 
cases is the circumstance that the effusion of fluid 
into the sac of this membrane, to which the carci- 
nomatous deposition gives rise, renders it extremely 
difficult to ascertain the real character of the dis- 
ease at the early period at which an operation 
would be desirable. The following case is recorded 
by Sir Everard Home.* — In December, 1781, a 
gentleman felt an uneasy sensation in the scrotum. 
On examining it he perceived the left testicle 
swelled, with a small degree of hardness to the 
touch. He immediately applied to a surgeon, who 
told him that the disease was a hydrocele, and 
advised him to let it alone till it became large, 
when it would be necessary to perform an opera- 
tion, which would effectually cure him. From that 
time to the beginning of March, 1782, the swelling 
gradually increased, the pain became acute, and the 
hardness increased. About this period two other 
medical gentlemen saw him : they were of opinion 
that the disease was complicated, and by no means 
a simple hydrocele ; therefore desired him to do 
nothing for a fortnight or three weeks, and then 

* Observations on Cancer, p. 125. 



CARCINOMA OF THE TUNICA VAGINALIS. 383 

they would see him again. In the mean time he 
was advised to apply to a surgeon noted for curing 
this complaint, who made two or three punctures 
for the palliative cure of hydrocele, assuring the 
patient that the disease was of that nature. On 
finding a failure of the good effects which had been 
promised, he again applied to his former surgeon, 
with the inflammation, pain, and swelling much 
increased. At this time Mr. Hunter was called in, 
and it was thought advisable to open into the 
tumour, to ascertain the real nature of the disease, 
and then to proceed accordingly. This was done ; 
and, on examining the substance of the tumour, it 
appeared to be composed of a thick coat, within 
which was a grumous and gelatinous substance. 
From this appearance of the tumour it was thought 
advisable to remove the whole, which was imme- 
diately done. Some of the skin, which was diseased 
and adherent to the fore part of the tumour, was 
also removed. The tumour was found to consist 
of a thickened tunica vaginalis, filled with a firm 
coagulum of blood, which, in some parts, had lost 
its red particles, the whole appearing like a mottled 
swelling ; and the testicle entire in the posterior 
part, only appearing to be squeezed into a smaller 
size than natural, from the pressure of this sub- 
stance in the tunica vaginalis. The parts healed 
up readily, but some months after a swelling on 
the lower and left side of the abdomen was ob- 
served. He was sent to sea ; but the swelling 
increased, and he became weak, hectic, and died. 
On examining the body there were found large 



384 CARCINOMA OF THE TUNICA VAGINALIS. 

masses of swellings, which were not much firmer 
than strong coagulated milk with the whey in it. 
These masses extended up the left side along the 
back, as high as the diaphragm. The epiploon ap- 
peared to have a large mass in it, connecting the 
colon, stomach, and other viscera together. The 
liver was studded full of small tumours, about the 
size of a bean, of the same structure ; and the sper- 
matic cord out of the belly had become thickened 
in the same way. 

Sir A. Cooper has described a similar case of 
carcinoma originating in the tunica vaginalis.* — 
Mr. T., aged sixty, rather of a bloated unhealthy 
appearance, fifteen months ago observed a swelling 
on the left side of the scrotum, which was un- 
attended with pain, but was accompanied by a 
formation of water in the tunica vaginalis. He 
applied to Sir B. Brodie, who directed the mercurial 
treatment, the application of leeches, and the re- 
cumbent posture ; but the swelling yielded little to 
this treatment. About two ounces of fluid were 
then drawn from the tunica vaginalis by puncture. 
The operation was repeated, but still the enlarge- 
ment and hardness remained. Sir A. Cooper was 
then consulted, and he recommended the same 
treatment. Afi:er a lapse of several weeks it was 
agreed that the diseased part should be removed, 
if, upon puncturing, the quantity of fluid should be 
found inconsiderable. On passing a lancet into 
the part in three different places, although fluctua- 

. * Lib. Cit. p. 207. 



COLLOID CANCER AND MELANOSIS. 385 

tion was apparently distinct, no water was found. 
The testicle was then removed by Sir B. Brodie, 
and upon dissection the appearances were as fol- 
lows : — The testis was perfectly sound The vas 
deferens could be injected to the beginning of 
the epididymis only. The epididymis was drawn 
to a great length by the swelling, and terminated 
in a membranous cord. The cavity of the tunica 
vaginalis was occupied by a spongy effusion, which 
had all the character of incipient fungus. The 
tunica vaginalis was thickened, and had a large 
piece of ossific matter in it. The spermatic cord 
was unaifected. This patient died of erysipelas ; 
and upon examination, his body was found in other 
respects free from disease. 

I have not myself met with any case of this 
kind. 



SECTION IV. 

COLLOID CANCER AND MELANOSIS OF THE TESTIS. 

The two forms of carcinoma termed colloid or ge- 
latiniform cancer, and melanosis, scarcely ever attack 
the testis. The only instance of the former that I 
know of, is a preparation very characteristic of the 
disease contained in the museum of Guy's Hospital. 
The organ is enlarged to four or five times its na- 
tural size, but preserves its oval form: there is 
scarcely any trace of the natural structui*e remain- 
ing. No history is attached to the preparation. 
Cruveilhier has related the case of a man who 
49 



386 CYSTIC DISEASE OF THE TESTIS. 

died at the age of forty-six of melanosis aifecting 
the hand, lungs, heart, stomach, and other parts.^ 
The right testis contained a little of the same matter, 
and the left a deposit the size of a nut. This is also 
the only case of melanosis of the testis on record 
with which I am acquainted. 



CHAPTER IX. 

CYSTIC SARCOMA OR CYSTIC DISEASE OF THE TESTIS. 

This is a rare affection, which has been described 
by Sir A. Cooper under the name of " the hydatid 
disease of the testicle." But as the cysts are not of 
the nature of animal hydatids, the term is an im- 
proper one, and should not be retained. 

The cysts constituting this disease contain fluid, 
and are developed in the substance of the testis. , 
They vary very much, both in number and size, I 
and in the appearance of their contents. They ' 
may be only two or three in number, or they 
may exist in a countless multitude throughout the 
gland. They vary also in size, from that of a millet 
seed to the dimensions of a pigeon's egg. At an 
early period they generally consist of smooth and 
slightly vascular cysts, closely adherent, and con- 
taining a transparent light-coloured fluid. The 
fluid is liable, however, to lose its transparency, 

* Anatomie Pathologique, liv. x\x. pi. 8 and 4. 



CYSTIC DISEASE OF THE TESTIS. 587 

and sometimes becomes thick, viscid, and albumi- 
nous, and even tinged with blood. Inflamma- 
tion occasionally occurs, and coagulable matter is 
effused into them, and they become more or less 
thickened. Sometimes small lobulated growths arise 
from a part of the walls of the cyst, and increase 
until the cavity is partly or wholly filled and ob- 
literated by them, in the same manner as in cystic 
disease of the mamma. The cysts usually increase 
at the expense of the secreting structure of the 
testis, which becomes atrophied and displaced from 
the pressure they produce. When inflammation 
takes place, fibrine is effused between as well as 
within the cysts, and becomes organized ; so that 
eventually no trace is perceived of the natural 
structure of the testis : the whole character and ap- 
pearance of the part are completely changed, the 
organ being partly solid, and partly composed of 
cysts containing fluid. At an advanced period, 
particularly when the volume of the testis is much 
increased, the surfaces of the tunica vaginalis are 
more or less adherent, and, as well as the tunica 
albuginea, thickened. In old cases also the tumour 
is intersected with fibrous bands, and the parietes 
of the cysts are sometimes transformed into car- 
tilage or bone. 

The mode of origin of these cysts has not been 
satisfactorily made out. Sir A. Cooper was inclined 
to the opinion that they are formed of enlarged 
and obstructed seminiferous tubes ; for he remarks, 
" Although at first sight they appear to be cysts, 
yet when traced they are not distinct bags, but send 



388 



CYSTIC DISEASE OF THE TESTIS. 



out solid processes by which they are connected 
with other bags."* They seem to me to be ana- 
logous to the sero-cystic tumours of the breast ; which 
appear to be formed by a morbid dilatation of the 
lactiferous tubes. They are evidently quite distinct 
from the little cysts so commonly developed in the 
head of the epididymis ; which part, indeed, is rarely 
affected in this disease. In a testis greatly enlarged 
by it^ I found the epididymis perfectly healthy. 




* Lib. eit. p. 



L. Section of a cystic tumour of the testis, showing a multitude of 
cysts of various shapes and sizes, with solid matter interposed between 
them. The natural structure of the gland is wholly destroyed. 



CYSTIC DISEASE OF THE TESTIS. 



389 




Some splendid specimens of cystic disease of the 
testis are preserved in several of the pathological 
museums in the metropolis. The accompanying 
wood-cuts, which exhibit the various characters and 
appearances presented by the disease, are taken from 
two specimens contained in the museum of the Col- 
lege of Surgeons. They are reduced in size about 
one half One of the specimens measures five 
inches in its longest diameter, and three inches in 
its smallest. 

The origin of this disease is sometimes attributed 
to a blow, but it usually commences without any 
apparent cause. 



M. Section of another tumour of the same kind ; the cysts of 
larger size. 

1, 1, 1. Lobular growths from the parietes of the cysts filling and 
obliterating them. 



390 CYSTIC DISEASE OF THE TESTIS. 

Symptoms. — The swelling to which the cystic 
disease gives rise takes place imperceptibly, very 
slowly, and without producing pain. After existing 
for several months, it occasions a chronic indolent 
tumour of an oval shape, which seems to fluctuate 
indistinctly, and is scarcely at all tender or painful. 
The surface of the tumour is generally smooth and 
even, but it is sometimes irregular ; and the disease 
being confined to the body of the gland, the epi- 
didymis may often be distinguished in its healthy 
state. But in other cases, especially at an advanced 
period, the epididymis is lost in the general tume- 
faction. When the tumour attains a large size it 
is inconvenient from its bulk, and unless well sup- 
ported it occasions a dragging sensation and uneasi- 
ness in the loins. The disease usually commences 
at the middle period of life ; but I have not myself 
met with it later than between the ages of forty 
and fifty. 

Diagnosis, — Cystic disease of the testis may be 
mistaken for hydrocele and encephaloid cancer of 
the testis, and the diagnosis is often very difficult. 
The tumour is of an oval shape, not pyriform, as in 
hydrocele ; it feels heavier, and fluctuates less dis- 
tinctly ; and there is an absence of the pain ex- 
perienced in compressing the part usually occupied 
by the testis in hydrocele. The swelling also is 
not transparent. Notwithstanding these distinctive 
marks, the surgeon is very liable to err ; and Sir A. 
Cooper admitted that he had been two or three 
times mistaken, and had put a lancet into the part 
expecting to find water issue, and a few drops of 



CYSTIC DISEASE OF THE TESTIS. 391 

blood only have followed * Where there is any 
doubt the grooved needle should be used. The 
characters of the tumour occasioned by cystic dis- 
ease are in general so similar to those produced by 
encephaloid cancer, that I can give no satisfactory 
directions for distinguishing them. The surgeon 
must be guided in his opinion by inquiries into the 
history of the case, and by noticing the condition 
of the cord and of the lumbar glands, and the state 
of the patient's health, which are unaffected in the 
cystic disease, but are liable to suffer in malignant 
enlargements of the gland. The tumour produced 
by the latter affection is also less even and regular, 
and makes more rapid progress than that occasioned 
by the cystic disease. 

Treatment. — No kind of treatment, either local 
or general, is of any service in this disease, the 
morbid changes being quite beyond the influence 
of remedies. The only means that can be adopted 
is the removal of the diseased gland, which should 
be performed as soon as the size and weight of the 
tumour are productive of inconvenience and suffer- 
ing ; and the disease being confined to the testis, 
there is no liabiHty afterwards to a return of the 
affection in other parts, 

* Lib. cit. p. 84. 



L 



392 FIBROUS TRANSFORMATION OF THE TESTIS. 

CHAPTER X. 

FIBROUS TRANSFORMATION OF THE TESTIS. 

The testis has in some few instances been found 
transformed into fibrous tissue, its secreting struc- 
ture having wholly disappeared. It seems that the 
cellular tissue naturally entering into the com- 
position of this organ becomes thus changed, and 
that new fibrous tissue is developed, which, by its 
pressure, causes atrophy and a total obliteration of 
the seminiferous ducts. In some instances, the 
structure into which the testis is converted is a loose 
fibrous tissue infiltrated with a watery fluid ; more 
frequently, it is close, dense, and firm, and even car- 
tilaginous, exactly resembling the fibrous tumour 
of the uterus. Occasionally it is interspersed with 
two or three small cells containing a serous fluid. 
The size of the testis sometimes remains unaltered ; 
at other times it is increased or slightly diminished. 
This lesion differs from the fibrous remains of the 
atrophied testis, since the organ chiefly consists of 
newly developed or transformed tissue, and not 
merely of the dehris of old. This disease is not 
unfi-equently accompanied with adhesions of the 
tunica vaginalis. 

The fibrous transformation of the testis is rather 
a rare pathological change. At page 78 I have 
described a case of imperfect descent of the testis, 
in which the gland, though reduced in bulk, had 
evidently undergone this conversion. In Cruveil- 



FIBROUS TRANSFORMATION OF THE TESTIS. 393 

hier's Anatomie Pathologique,"^ there is an ex- 
cellent representation of the disease. The testis 
was removed from a patient at the Hopital Beaujon 
by M. Marjolin. It was twice the natural size, and 
very heavy. It offered a good deal of resistance 
to the knife, and creaked when cut ; and it was 
entirely composed of a number of grayish-white 
fibres intersecting each other and arranged in 
lobules, similar to the fibrous tumour of the uterus. 
So far as I know, this disease is unattended with 
pain or any peculiar symptoms besides great indur- 
ation of the whole organ ; and the change is one 
over which neither general nor local treatment can 
exert much control. Sir B. Brodie mentions, that 
he extirpated a testicle that had undergone this 
fibrous conversion ; between six and twelve months 
after the operation the other testicle became hard 
and enlarged, and apparently affected in a similar 
way. As an experiment he gave the patient iodine 
internally, and rubbed the iodine ointment on the 
testicle also. The hardness became in some degree 
diminished, and the progress of the disease stopped ; 
and the patient left the hospital with the greater 
part of the remaining testicle in a sound state. The 
disease is not of a malignant character ; and as in 
general it produces little or no inconvenience, the 
extirpation of the gland is rarely required. The 
operation is occasionally undertaken from appre- 
hension of the disease being scirrhous or malignant. 
Mr. Travers mentions a case in which the gland was 
removed, owing to the person affected being impa- 

* Liv. V. pi. 1. fig. 3. 
50 



394 FIBROUS TRANSFORMATION OF THE TESTIS. 

tient for its extirpation on this account.* The 
gland being quite useless when in this state, there 
is no particular objection, after other means for the 
reduction of the induration have failed, to castration 
to allay the patient's fears, and to remove a con- 
stant source of uneasiness from his mind ; but it is 
not a disease which absolutely requires the opera- 
tion. 



CHAPTER XL 

OSSIFIC DEPOSITS IN THE TESTIS. 

Earthy matter is met with in the testis under two 
forms : 1. Laminated, and often mixed up with car- 
tilage ; and, 2, as an inorganic cretaceous deposit. 
In the first form it is usually deposited between the 
tunica vaginalis testis and the tunica albuginea, 
in little bony or cartilaginous patches, in which a 
jfibrous arrangement may be recognised. I have 
frequently found one or two irregularly-shaped pro- 
jecting ossific bodies scarcely larger than a pin's 
head attached to the tunica vaginalis, covering the 
upper part of the testis. Ossific matter occurs also 
on the adherent surface of the tunica vaginalis in 
old cases of hydrocele, where it has been found so 
abundant as to form a complete ossific capsule. It 
has been said that the epididymis alone may be 

* Medico-Chirurgical Transactions, vol. xvii. p. 327. 



OSSIFIC DEPOSITS IN THE TESTIS. 395 

encased in bone, the testis being free ; but this I 
have never seen. Earthy matter in this form is not 
often observed in the substance of the testis. The 
gland, however, when atrophied and reduced to a 
mere fibrous tissue, occasionally undergoes both the 
cartilaginous and osseous transformation. The ac- 
cidental cysts developed in the testis are likewise 
liable to similar changes. 

109 parts of ossific matter from the tunica vagi- 
nalis, divested of membrane and dried, were found 
by Mr. Barry to consist of 

Phosphate of lime - - - 45 

Carbonate of lime (with a trace of magnesia) 17 
Animal matter - - - - 38 



100* 

These changes possess more pathological interest 
than practical importance. The following case, 
however, is interesting. — A soldier, about seventy 
years of age, whose left testis was partly converted 
into bone, and felt extremely firm and indurated, 
was an out-patient at the London Hospital under 
Mr. Adams for many weeks. He applied on account 
of the organ becoming painful and inflamed. After 
some time it suppurated ; and the pus, on being 
discharged, had the usual offensive smell of an 
abscess connected with dead bone. The ossific 
matter came away by degrees in small pieces, which 
amounted to nearly one hundred, and the patient 
ultimately recovered with an atrophied testis. 

* Sir. A. Cooper on the Diseases of the Testis, p. 245. 



396 LOOSE BODIES IN THE TUNICA VAGINALIS. 

In the second form the earthy matter is deposited 
in an irregular cretaceous mass containing very 
little animal matter ; in appearance resembling 
mortar, and very similar to the earthy substance 
found in the lungs and bronchial glands. It is 
generally met with in the globus major of the epi- 
didymis, and sometimes in the globus minor, but 
very seldom in the body of the testis. I am inclined 
to believe that it results from the transformation of 
tubercular matter deposited in the testis in early 
life. (See observations at page 349, and the accom- 
panying figure.) Andral mentions that he once 
discovered a calculous concretion about the size of 
a nut betv^een the tunica albuginea and the tunica 
vaginalis, which latter was elevated over the tumour, 
the testis and tunica albuginea being unaltered.* 



CHAPTER XII. 

LOOSE BODIES IN THE TUNICA VAGINALIS. 

Loose bodies are occasionally found in the cavity 
of the tunica vaginalis. They are small in size, 
and of an oval flattened shape ; and their surface 
is smooth and polished. Their texture is in most 
instances elastic and homogeneous, resembling the 
unattached cartilages found in joints ; and points 

* Precis d'Anatomie Pathologique, torn. iii. p. 669. 



LOOSE BODIES IN THE TUNICA VAGINALIS. 397 

of ossification are often contained in their in- 
terior. In some specimens I have observed the 
cartilaginous matter to be arranged in concentric 
laminae. The loose body is sometimes entirely 
composed of bony matter. On examining a thin 
lamina of one in the microscope, I could distinctly 
see small oval corpuscules, with a number of lines 
proceeding from them, very similar to those of bone 
represented in pi. 1, fig, 13, of Miiller's Physiology 
by Baly. Richter of Gottingen met with three 
round bodies in the tunica vaginalis, which were 
quite hard, and of the size of a very large hazel- 
nut ; but they rarely attain so large a size as this.* 
They seldom exceed three in number ; and they 
occur generally in combination with hydrocele, 
the loose bodies being the original disease, since in 
their movements in the cavity of the tunica vagi- 
nalis they promote a greater secretion of fluid 
from the serous membrane, in the same way as a 
loose cartilage in a joint excites an increased syno- 
vial secretion from the membrane by which it is 
lined. In some cases the surface of the tunica 
vaginalis is found thickened and uneven. 

The manner in which these loose bodies origi- 
nate does not differ essentially from the mode of 
developement of loose cartilages in the interior of 
joints. Deposition takes place between the tunica 
vaginalis testis and the tunica albuginea ; and the 
former membrane is gradually protruded, until the 
cartilaginous or ossific body forms a pendulous 

* Medical and Chirurgical Observations, tr. 



398 SPERMATOCELE. 

tumour, which, being attached merely by a slender 
stalk, is accidentally separated in the motions of 
the testis, and is thus left loose in the cavity of 
the tunica vaginalis. These bodies have been ob- 
served in the various stages of their developement. 
In a loose substance of the size of a small grape of 
firm consistence, and possessing a bony nucleus, 
found in a case of hydrocele, Morgagni noticed a 
short and slender neck by which it had been ad- 
herent.* But in general there is no trace of the 
original attachment left on either the loose body or 
the tunica vaginalis. 



CHAPTER XIII. 

SPERMATOCELE. 



This term implies a tumour formed by a collection 
of the seminal fluid ; but it has occasionally been 
applied by writers to swellings produced by vari- 
cocele and other affections of these parts. I have 
sometimes noticed in testes, otherwise healthy, 
small collections of thick caseous matter of a yellow 
colour (apparently inspissated sperm) blocking up 
and distending some of the efferent tubes of the epi- 
didymis, and the round dilatations frequently con- 
nected with them ; but, with this exception, I know 
of no affection of the testis to which the term sper- 

* Cooke's Morgagni, vol. ii. p. 429. 



FCETAL REMAINS OF THE TESTIS. 399 

matocele can be properly applied. It is possible 
that the semen might collect in and dilate one or 
more of the seminiferous ducts in the testis, in con- 
sequence of some obstruction, and thereby consti- 
tute a swelling of a similar character to the lacteal 
tumour of the breast ; but amongst the many hun- 
dred testes I have examined, I have not met with 
a single instance of the kind.^ 



CHAPTER XIV. 

F(ETAL REMAINS IN THE TESTIS. 

The remains of a foetus have in rare instances 
been found in the scrotum in connexion with the 
testis. Several examples of the kind have been 
collected by Ollivier (D'Angers).t In all these 
cases it was evident that the scrotal inclusion had 
succeeded to an inclusion originally abdominal ; 
that is to say, that the organic debris were first 
situated in the abdomen along with the testis, 
having accompanied the gland in its progression out 
of that cavity. In two of the cases in which the 
particular testis was indicated, the right was the 
one affected. M. Velpeau has recently communi- 

* I have found the semen thus collected in the lower part of the 
epididymis of the dog, some months after excising a portion of the vas 
deferens. 

\ Memoire sur la Monstruosite par Inclusion ; Arcliives Generales 
de Medecine, torn. xv. p. 540. 



400 ENTOZOA IN THE TESTIS. 

cated to the Academy of Sciences an account of the 
case of a man, twenty-seven years of age, whose 
right testis he removed by operation for a con- 
genital enlargement, which was found to be occa- 
sioned by the presence of nearly all the anatomical 
elements of a foetus.* 

Dr. Andre removed by ligature a tumour con- 
taining hair and several teeth from the right testis 
of a boy seven years of age. The boy was well 
formed at birth ; but at the end of a year his 
parents observed that the right testis was larger 
than the left. In six months afterwards the child 
was operated on for hydrocele : a little serum 
escaped, but the testis remained larger in size than 
natural. When he was nearly seven years of age 
the gland became swollen and painful : a sore 
formed in the scrotum ; and a fleshy growth pro- 
truded, which was found to contain several long 
hairs and teeth.t 



CHAPTER XV. 

ENTOZOA IN THE TESTIS. 



The Entozoa very rarely indeed infest the testis ; in 
the examination of a large number of testes I have 
not met with a single example. Sir A. Cooper 

* Gazette Medicale de Paris, Fev. 15, 1840. 

I Memoires de FAcademie Royale de Medecine, torn. iii. p. 480. 



IRRITABLE TESTIS. 401 

mentions an instance of an independent cyst, pro- 
bably an acephalocyst, which was found accidentally 
on dissection in a sac connected with the epididy- 
mis."* Dr. Baillie once met with Rjilaria medinen- 
sis, or Guinea- worm, in a firm cyst adherent to the 
testicle. 



CHAPTER XVI. 

NERVOUS AFFECTIONS OF THE TESTIS. 

We may distinguish two kinds of nervous affections 
of the testis. One which, in my experience, is the 
more common of the two, consists in an exaltation 
of the natural sensibility of the part ; and it is to 
this complaint that the term " irritable testis" used 
by writers more properly applies. The other is a 
true neuralgic affection of the spermatic nerves. 

SECTION I. 

IRRITABLE TESTIS. 

A patient suffering from an irritable testis cannot 
in many cases bear the least pressure on the gland, 
not even the contact of his dress : he shrinks when 
the part is handled in the most gentle manner ; and 
the motions of the testis often occasion so much 
uneasiness that he is prevented from taking exer- 

* Lib. cit. p. 90. 
51 



402 IRRITABLE TESTIS. 

cise, and is compelled to remain constantly at rest 
in the recumbent position. The morbid sensibility 
is not always confined to the testis, but sometimes 
extends up the cord to the loins, so that the passage 
of faeces through the colon and its distension by 
flatus are liable to cause uneasiness. The pain is 
in some degree increased when the patient is in the 
erect position and the testis without support. It is 
frequently referred to one particular spot on the 
gland, which possesses more exquisite sensibility 
than the surrounding parts. In some instances 
both testes are affected, one perhaps more than the 
other ; in other cases the morbid sensibility is con- 
fined to one side, generally the left. There is no 
perceptible alteration in the parts, except occasion- 
ally a degree of fulness, more particularly in the 
spermatic cord ; slight varicose dilatation of the 
veins, and a relaxed state of the scrotum. The 
complaint is usually tedious, and lasts many months. 
The persons subject to it are those of a weak and 
irritable habit, who are dyspeptic or hypochon- 
driacal, and unequal to much bodily or mental exer- 
tion. In this affection all enjoyment of life and its 
pleasures disappears ; the sufferers concentrate their 
thoughts upon their maladies ; they fancy they shall 
never get cured ; and whilst some become uneasy 
as to the effect of the complaint in impairing the 
integrity of the gland, and rendering them impo- 
tent, others as urgently desire castration as the sole 
means of relief from their distress. 

Morbid sensibility of the testes is in general 
intimately connected with the state of the genital 



IRRITABLE TESTIS. 403 

functions, and is frequently dependent on abuses of 
them. In several instances I have known it to be 
consequent on onanism, and on involuntary seminal 
emissions ; and I have found it disappear when the 
seminal discharges ceased. It sometimes occurs 
after cessation from free indulgence in sexual inter- 
course ; and it occasionally affects persons exposed 
to sexual excitement, but who have not been able to 
indulge their passions. In such cases the glands are 
very much in the same condition as the tender and 
swollen mammas at the commencement of lactation 
or of weaning. In a person of chaste habits thus 
affected, I was informed that the morbid sensibility 
disappeared on marriage. The testes, like the 
mammae, often also become affected with morbid 
sensibility about the period of puberty. The com- 
plaint sometimes succeeds an attack of orchitis. 
Though troublesome, it generally disappears either 
spontaneously or under treatment after a longer or 
shorter duration. 

Treatment,— \b. the treatment of morbid sensi- 
bility of the testis the first object is to endeavour, 
if possible, to get rid of the cause of the affection. 
In many cases, however, this cannot be ascertained, 
or is only suspected. Attention must be paid to 
the state of the general health and of the digestive 
organs. Steel medicines and quinine may often be 
given with benefit. In many cases much service 
is derived from change of air and scene, so as to 
amuse the mind, and prevent the sufferer from 
brooding over his complaints. It often happens 
that when the mind is occupied, and the patient 



I 



404 IRRITABLE TESTIS. 



obliged to exert himself, he is free from suffering. 
As in many other nervous affections, the complaint 
becomes worse and aggravated by too much atten- 
tion being paid to it. Advantage is often derived 
from cold bathing, and sponging the scrotum with 
iced water. I have sometimes succeeded in pro- 
curing relief with the douche bath, by causing a 
stream of cold fresh-drawn spring water to be 
directed on the scrotum so as to produce a power- 
ful effect. The eye-douche bath, or a kettle, will 
answer the purpose very well, and the application 
should be made at least once daily. Enclosing the 
scrotum in a belladonna plaister, and supporting the 
parts, also sornetimes afford relief The testis may 
at the same time be preserved from the effects of 
friction and contact of the dress, when the patient 
moves about, by lining a full-sized suspender with 
a layer of soft wadding or wool. But the surgeon's 
success in the treatment of these cases mainly de- 
pends on his being able to ascertain the true cause 
of the complaint. — A young man set. 22, a sack 
and tarpauling maker, applied to me for relief on 
account of distressing pains in the testicles. He 
stated that he was a single man, and had suffered 
from these pains for about two months. He was 
of a weak frame of body, thin and pale ; and had a 
languid, melancholy countenance, and was subject 
to headache. His voice was feeble, and he trembled 
as he^entered the room. The penis and testes were 
small in size ; the latter were extremely tender 
when handled, so that he could scarcely suffer me 
to touch them. He stated that he had no discharge 



IRRITABLE TESTIS. 405 

from the urethra, and had never been affected with 
syphilitic disease. I directed the testes to be sup- 
ported and kept cool, and as much as possible pro- 
tected from friction, and ordered the shower bath 
and steel medicines. Suspecting, from his general 
appearance and the character of his countenance, 
that he was addicted to onanism, I twice questioned 
him upon the subject, but without eliciting that he 
was habituated to this vice. But after he had at- 
tended for some time, and the above remedies, as well 
as arsenic, quinine, purging, blisters to the loins, &c. 
had been tried without any decided improvement, 
I made further inquiries, and ascertained that he 
had been for years subject to involuntary seminal 
emissions, which occurred without erections both in 
the daytime and at night, and often on evacuating 
the bowels. I introduced into the urethra a full- 
sized bougie, and found that it produced great pain 
on reaching the prostatic part of the canal. I then 
applied the nitrate of silver to this part of the 
urethra by means of Lallemand's instrument (see 
page 444.) The application was transient, but the 
patient instantly fainted from the sharp pain which 
it produced. The effects of the lunar caustic 
subsided in about a week. No emissions occurred 
afterwards. The pains in the loins and morbid 
sensibility of the testicles soon completely subsided ; 
he lost his headache, and in a few weeks became 
much improved in health, when he was discharged 
cured. I have treated, with a similar application 
of the nitrate of silver to the prostatic part of the 
urethra, and with the same success, two other cases. 



n 



406 NEURALGIA OF THE TESTIS. 



in which the morbid sensibility of the testis was 
less severe, but dependent on the same cause as in 
the one just related. 

Castration should never be performed for this 
affection ; for the complaint generally ceases sooner 
or later, and can almost always be relieved by 
judicious treatment. Romberg relates,^ that he 
had a patient under his care who was attacked 
with this disease at the time he was engaged to be 
married. In spite of all the serious objections of a 
distinguished surgeon whom he had called into 
consultation, in spite of his own earnest representa- 
tion, the patient insisted upon having castration per- 
formed ; and the operation was accordingly done, 
that no greater mischief might ensue. Eight days 
afterwards the old pain had taken up its seat in 
the other testis ; but this its owner preferred keep- 
ing, the marriage being at hand, and he very soon 
recovered completely. The testis which had been 
removed, with the exception of a few dilated ves- 
sels, did not differ in the slightest degree from the 
normal state. 

SECTION II. 

NEURALGIA OF THE TESTIS. 

In the nervous affection just described there is 
merely morbid sensibility ; pain seldom being ex- 
perienced whilst the patient remains at rest, and the 
gland ^nd spermatic cord are supported, and entirely 

* Lehob der Nervenkran^kheiteii, S. 142. 



NEURALGIA OF THE TESTIS. 407 

free from pressure or rough contact with the dress. 
The nerves of the testis are liable, however, to a 
more painful affection, possessing the characters of 
tic douloureux or true neuralgia, in which the pain 
is sudden, severe, and remittent, and occurs in pa- 
roxysms of variable duration, generally at irregular, 
but occasionally at regular intervals. The pain is 
sometimesof an acute dartingor lancinating descrip- 
tion, at other times of a dragging or pricking nature ; 
and it is commonly attended with forcible retrac- 
tion of the testis to the groin by spasmodic action 
of the cremaster muscle, and occasionally with 
nausea and vomiting. Dr. Graves mentions a case 
in which the patient, when attacked with a pa- 
roxysm, would throw himself on the floor and roll 
about in the greatest agony, covered with a cold 
perspiration.^ During the intervals of the pa- 
roxysms the testis may sometimes be freely handled 
without causing pain ; but frequently the neuralgia 
is combined with morbid sensibility, and a paroxysm 
is readily induced by the slightest pressure. In two 
cases, in which the neuralgic symptoms were slight, 
and appeared to depend on some affection of the 
kidney, the patient complained of a remitting pain 
or soreness at the crest of the ilium, near the an- 
terior superior spinous process, though there was 
no tenderness on pressure. 

In most cases of neuralgia testis, there is no 
disease or alteration in the gland ; but when the 
pains have been long-continued and iutense, the 

* Dublin Journal of Medical Science, vol. xiv. p. 371. 



408 NEURALGIA OF THE TESTIS. 

testis occasionally becomes swollen and tender, and 
affected even with a slight degree of inflammation. 

This painful affection is unaccompanied with 
fever ; but the digestive organs are usually out of 
order, and the health deranged from the acute 
suffering and disturbance of the patient's rest. 
The neuralgia is almost always confined to the 
spermatic nerves of one side, whilst in morbid 
sensibility both sides are as frequently implicated. 

Neuralgia of the testis occurs at all ages, and is 
a complaint which appears to arise from various 
causes. We have examples of it in the uneasiness 
in the testis and spasm of the cremaster muscle 
occurring in diseases of the kidney, and in the 
severe neuralgic pains usually experienced during - 
the passage of a calculus along the ureter to the 
bladder. In treating of varicocele, I have stated 
that a dilated state of the spermatic veins is oc- 
casionally accompanied with neuralgic pains in the 
testis ; and as the latter occur subsequently to the 
appearance of the former, and subside on its re- 
moval, and often when the patient is in the recum- 
bent position, we may conclude that the morbid 
condition of the veins is in some way the cause of 
the neuralgia. But the pathological cause of neu- 
ralgia of the testis is seldom so obvious as in the 
above instances. The testis has been accurately 
examined, and the nerves of the cord have been 
carefully dissected out, but nothing to account for 
this distressing complaint has been discovered."* 

* A perfectly healthy testicle, extu-pated by Sir W. Blizard on 
account of this disease, is preserved in the museum of the College of 
Surgeons. 



NEURALGIA OF THE TESTIS. 409 

Its primary seat has been referred to the spinal 
cord ; in some instances it has appeared to depend 
on derangement of the digestive organs,"^ and in 
others it was evidently connected with a disposition 
to gout. In several cases, also, it has succeeded 
an attack of orchitis, continuing to distress the 
patient after all inflammation has subsided, and 
recurring or increasing whenever he gets out of 
health ; but in the majority of instances it is very 
difficult and even impossible, to make out either the 
cause or origin of the neuralgic pains. 

Treatment. — In cases of neuralgia testis de- 
pendent on renal disease, the passage of a calculus 
along the ureter, or varicocele, the treatment must 
chiefly be directed to the relief of the complaints to 
which the nervous affection owes its origin. The 
pains may, however, be mitigated by opiates, warm 
baths, and fomentations of hops or poppy heads. 
When the disease is connected with derangement 
of the digestive organs, or a tendency to gout, mea- 
sures must be taken for their correction. In all cases 
particular attention should be paid to the condition 
of the urine. Cases of neuralgia testis, in which 
neither the cause or seat of disease can be discovered, 
must necessarily be treated empirically. Those of 
an intermittent character are sometimes benefited 
by quinine in large doses, as five grains three times 
a day, or the liquor arsenicalis. In Dr. Graves' 
acute case of neuralgia previously alluded to, the 

* Vide an interesting case related by Sir B. Brodie, London Medi- 
cal Gazette, vol. xiii. p. 620. 

52 



410 NEURALGIA OF THE TESTIS. 

complaint yielded to large doses of the sesquioxide 
of iron freshly prepared, and frequent inunction of 
the testicle and cord with belladonna ointment. 
The oil of turpentine sometimes proves very effica- 
cious in these cases, when not dependent on renal 
disease. It may be given in the form of linctus, 
prepared as follows : — Take the yolk of one egg ; 
oil of turpentine 3iij ; syrup of orange peel and of 
tola, of each 3ij ; and of laudanum 3J. Three table 
spoonfuls to be taken daily. 

Other remedies of reputed efficacy in neuralgia 
have been tried in this affection, but have all dis- 
appointed expectations much oftener than they 
have cured. The various preparations of opium, 
hyoscyamus, conium, and aconitum, often affi^rd, 
however, temporary, if not permanent relief; and 
they greatly contribute to mitigate the patient's 
sufferings, when incapable of removing the disease. 
The scrotum may be blistered, and the surface 
dressed with an ointment containing the acetate or 
muriate of morphia, in the proportion of five grains 
to the ounce. The application of a belladonna 
plaister often gives relief An ointment containing 
one grain of aconitina to a drachm of lard, smeared 
over the scrotum in the direction of the cord twice 
a day, will sometimes arrest the pains for many 
hours. The tincture of aconite^ properly prepared, 
and applied to the scrotum with a piece of sponge, 
produces a numbing sensation, and is efficacious 

* Unless care be taken that these expensive preparations are 
genuine, the practitioner will often be disappointed in their effects. 



NEURALGIA OF THE TESTIS. 41 I 

in relieving both the morbid sensibility of the testis 
and neuralgic pains. I have sometimes known 
benefit derived from the extract of hyoscyamus, in 
doses of ^ve grains, combined with half a grain 
of the acetate of morphia, taken twice a day. 

Local bloodletting seldom proves of more than 
temporary service, and is sometimes hurtful by les- 
sening the patient's powers. I have no confidence in 
counter-irritation, or the veratria and iodide of mer- 
cury ointments, which too often cause additional 
suffering without the compensation of mitigating 
the nervous disease. No benefit is derived from 
the action of mercury, except when given in small 
doses to improve the state of the secretions. In 
the treatment of these obstinate and protracted 
cases, the practitioner often labours under a disad- 
vantage, owing to the patient not obtaining the 
speedy relief he expected, losing confidence in his 
attendant, and seeking other advice ; so that he 
goes from surgeon to surgeon, without affording 
any one the opportunity of steadily persevering in 
the management of the case. 

In cases in which remedies of every kind and in 
all shapes have been repeatedly tried, and have as 
frequently failed in affording more than temporary 
relief, the patient's life is sometimes rendered so 
truly miserable that his patience is exhausted, and 
he becomes anxious to undergo some operation, 
and even that of castration, to get rid of a disease 
of so obstinate and harassing a character. Opera- 
tions, however, for the cure of neuralgia are in 
genera] very precarious and unsatisfactory, and the 



412 NEURALGIA OF THE TESTIS. 

more extended our experience the less encourage- 
ment we find to repeat them. When the disease 
has a constitutional origin, or its true seat is at a 
distance from the part where its painful effects are 
manifested, and beyond the reach of the knife, it 
would be unreasonable to expect any beneficial 
result from the division of the nerves, or the re- 
moval of the part to which the pains are referred ; 
and we find that in several of the cases in which 
the operation has been resorted to no benefit has 
resulted from it. 

Dr. Macculloch mentions a case of neuralgia 
testis, in which, after a long period of suffering, 
the gland was extirpated in the usual manner, but 
the disease returned in the cord* Mr. Russell has 
given a brief account of three casesof this affection 
which occurred in Edinburgh. In one, in the per- 
son of a medical practitioner, castration was per- 
formed on account of the intolerable suffering, and 
with perfect relief The patient recovered his 
health, strength, and spirits, which had been im- 
paired by the severity and continuance of his com- 
plaints. A practitioner, encouraged by the success 
of this operation, adopted a similar practice in a like 
case, which, however, was not followed by an equally 
favourable result ; as the patient experienced in the 
first instance but imperfect relief, while the com- 
plaint gradually returned, increasing in severity, 
till at last it attained its original violence. The 
next case that occurred was treated upon other 

* Essay on the Marsh Fever and Neuralgia, p. 77. 



NEURALGIA OF THE TESTIS. 413 

principles. The practitioner advised the patient to 
submit to his sufferings with patience, in the hope 
that time would at last accomplish a cure. The 
patient followed this advice, and was relieved from 
his misery in the course of eighteen months.^ Sir 
A. Coopor has resorted to castration in three cases 
of neuralgia testis, in all of which the result appears 
to have been satisfactory, the patients having re- 
covered, and afterwards continued free from any 
return of their distressing complaint. — Case 1. 
Mr. G., in October, 1815, contracted a gonorrhoea, 
and in consequence had inflammation of the right 
testicle, for which he applied fomentations, and 
took aperient medicines. The testicle continued 
swollen and painful until June, 1816, when the 
employment of plaisters removed all inconvenience. 
A slight degree of pain returned at intervals until 
June; 1817, when he was again relieved by plaisters, 
and thought himself sufficiently well to join his 
regiment. The exercise which his duty obliged 
him to take soon occasioned so much pain, that 
during the winter of 1817 and spring of 1818 he 
scarcely had a moment's respite. In May he re- 
turned to England, and bathed in the sea till Sep- 
tember, at which time the pain was nearly removed ; 
but he was unable to walk or ride. He subse- 
quently became unable to walk ten yards without 
experiencing considerable pain. The only thing 
which appeared to relieve him was violent motion 
in a rough carriage. On account of the continued 

* Observations on Diseases of the Testicle, p. 186, et scq. 



414 NEURALGIA OF THE TESTIS. 

pain, confinement, consequent depression of spirits, 
and loss of health, he determined on having the 
testicle extirpated. It was removed on the 1st of 
March, 1819. The wound healed slowly, and one 
or two small abscesses formed in the scrotum ; but 
he ultimately did extremely well, having no return 
of pain in the spermatic cord. — Case 2. Captain P. 
had an irritable state of the left testis, which com- 
menced in March, 1818. The veins of the sper- 
matic cord felt distended ; the part was exquisitely 
tender to the touch ; and exercise produced a 
degree of suffering which was intolerable, if the 
part was not supported. He could not rest on the 
side, or bear the slightest pressure on the testis. 
He had increased pain in coition ; and after it the 
part felt full and loaded. He was somewhat, but 
only for a time, relieved by the hot bath or foment- 
ations. He tried blistering at five different times ; 
applied two hundred leeches on separate occasions 
to the affected part ; employed various lotions, 
opium, and belladonna, with every medicine which 
seemed likely to be useful in lessening the irrita- 
bility, but all without effect. Sir A. Cooper re- 
moved the testicle for him in 1823. He quickly 
recovered from the operation, and felt very grateful 
for his restoration to comfort and society. — Case 3. 
This subject was a gentleman who came from 
America for advice, having tried every variety of 
medicine and local treatment without advantage. 
At his request Sir A. Cooper removed the part ; 
and he has since heard that the patient remains 
quite well. He said for several years past his left 



J^EURALGIA OF THE TESTIS. 415 

testicle had been larger than his right ; at times 
considerably so, especially when he had taken cold. 
In August last, after exposure to unusual fatigue, 
he had pain for the first time in the left thigh and 
groin, also in the testicle, which was much en- 
larged. In September a surgeon made an incision 
into it, and let out a large quantity of water. In 
a few days after the part again became painful : he 
applied poultices and fomentations. The pain con- 
tinued ; in about six weeks the operation was 
repeated, but very little water was drawn off. He 
took mercury until his mouth became sore, and 
lay in a horizontal position. A blister was sub- 
sequently applied to the scrotum. These remedies 
gradually reduced the testicle, but the pain con- 
tinued ; sometimes a sharp shooting pain in the 
groin, but generally a heavy, dull constant pain. 
He then applied leeches which produced debility ; 
since which he used a lotion of lead and opium. 
The pain was constant, and he could not stand ten 
minutes without increasing it considerably. There 
was great sensibility in the part, and the slightest 
touch was painful. He was subject to headache 
and other dyspeptic symptoms, and a long residence 
in warm climates had injured his constitution.* 

The details of these three interesting cases should 
be carefully examined, in order that the practice of 
so eminent a surgeon may not be made to coun- 
tenance the indiscriminate performance of an 
operation the general results of which are less 

* Lib. Cit. p. 69, et. seq. 



416 NEURALGIA OF THE TESTIS. 

satisfactory than might be inferred from these ex- 
amples. Their success may, I think, be accounted 
for. In all of them it is clear that the neuralgia 
had a local oriorin. In the second case it was com- 
bined with varicocele ; a complication which, it 
will be shown,* is of occasional occurrence, and 
admits of perfect relief by castration, the cause of 
the disease, viz. a morbid condition of the veins, 
being thereby removed, together with the testis. 
In the two other cases, it appears that the neu- 
ralgia was originally induced by an attack of 
orchitis ; and though it afterwards proved irreme- 
diable by antiphlogistic means, and persisted after 
all inflammation had subsided, the nerves affected 
were evidently those immediately connected with 
the testis, which having been removed, the painful 
sym.ptoms all ceased. In such cases, then, in which 
the neuralgia has a local origin, is confined to 
one side, and is clearly dependent on some change 
in the state of the nerves of the testis or cord, cas- 
tration might be performed when the symptoms 
are sufficiently severe, and the patient is willing to 
undergo it with a fair prospect of permanent relief. 
But in cases in which it is impossible to determine 
exactly the seat or the cause of the disease, the 
surgeon incurs no slight risk of failure ; and if he 
ventures to undertake the removal of so important 
an organ as the testis at the earnest entreaty of 
the sufferer, it would be his duty, as it would be 
his policy, fully to apprise his patient of the un- 
certainty of the result. 

* Vide Part III. Chap. 1. 



SYMPATHETIC DISORDERS OF THE TESTIS. 417 



CHAPTER XVII. 

SYMPATHETIC AND FUNCTIONAL DISORDERS OF THE 
TESTIS. 

Imperfect as is our knowledge of the sympathetic 
and functional disorders of the secreting glands, 
no organs present greater difficulties in this respect 
than the testes. Their functions are so involved 
in those of other parts, are influenced by such 
peculiar causes, and are so dependent on and mo- 
dified by particular events and circumstances, that 
the investigation of them, when disordered, neces- 
sarily becomes of a complex and difficult character. 
The product, too, of these glands is one the quali- 
ties of which it is almost impossible to appreciate, 
and which during life is never affi^rded in a pure 
and unmixed state ; and further, taking into ac- 
count the repugnance felt to such inquiries it is 
scarcely surprising that the subject has been but 
imperfectly investigated, and rarely treated of by 
the pathologist and practitioner. Indeed, the little 
information we possess respecting it is chiefly to be 
found under the head of Impotency in works on 
Medical Jurisprudence, in v/hich it is cursorily 
considered, principally in relation to points of 
medico-legal interest, and scarcely at all in reference 
to practice. 
The functions of the testicles may, like those of 

53 



418 SYMPATHETIC APsD FUNCTIONAL 

many other secreting organs, become suspended, | 
and be incapable of excitement ; or they may be 
exerted to excess, and be so abused as to be called 
into action by the slightest exciting causes. I shall 
in the first place, consider the former of these dis- 
orders, which will include the subject of impotency, 
so far as it depends on an imperfection in the action 
and condition of the testes. 

In speaking of the functions of the testes (page 
67) I pointed out how much these glands are under 
the influence of the brain, and noticed the striking 
effects of impressions on the mind in arresting their 
secretions ; and in Chapter II. Section 2, several 
cases have been mentioned in which the testicles 
had completely wasted after injuries to the head and 
brain, and also cases of idiots, whose generative 
organs were imperfectly formed, who had expe- 
rienced no desire for sexual pleasures. I will now 
adduce some additional facts in relation to this 
subject. — Hildanus mentions the case of a man ac- 
cused of impotency by his wife, who sued for a 
divorce. Nothing external was defective ; but the 
man stated that eight years previously he had re- 
ceived a blow on his head by a stick. From that 
period " confitebatur penem erigi non posse."^ — 
Mr. B., aged forty-one, a passenger on the railway 
between Boston and Providence, apprehending an 
accident, thrust his head out of window at the mo- 
ment that the train came in collision with another 
running in an opposite direction with fearful vio- 

* Opera Observationum et Curationum Medico-Chirurgicarum, 
p. 574. 



DISORDERS OF THE TESTIS. 419 

lence. Most of the passengers were thrown out, 
and seriously injured. Mr. B.'s head and neck 
struck against the edge of the window-frame with 
great force ; and he himself was thrown to th€ 
ground, where he remained for some time in a state 
of insensibility. He, however, regained his senses, 
and was conveyed home in a carriage. The surgeon 
on visiting him found him suffering great pain in 
the occipital region and upper part of the neck ; 
but ther€ was no indication of fracture of the skull 
or spine. On the second day after the accident he 
complained of a numbness in his right arm, and 
experienced difficulty in passing his urine. In the 
course of two weeks he was able to leave his bed, 
and walk in the street ; but his vision was defective. 
Between the fourth and fifth week after his injury 
he made the discovery that he had lost the desire 
and physical power for sexual intercourse, and that 
no amorous sentiment, or the approach of a female, 
could excite it. Under appropriate treatment the 
bladder gradually recovered its power, and his 
vision became perfect ; but the numbness of the 
right arm continued, and the generative functions 
remained impaired. His mental powers, particu- 
larly his memory of events, were also for a time 
seriously affected.^ Dr. Smyth, in some excellent 
observations on the subject of impotency, states 
that he has seen complete impotence (absence of 
erection) of three months' duration, accompanied 
by general emaciation and impairment of health, 

* Case related by Dr. Fisher. American JouTiial of the Medical 
Sciences, Feb. 1839, p. 357. 



420 SYMPATHETIC AND FUNCTIONAL 

excessive irritability of both mind and body, and 
considerable shrinking of the penis and testicles, 
occur in a strong young man of twenty-five from 
injury of the back part of the head. This gentle- 
man being engaged in a quarrel, received a blow 
on the face which stunned him ; and having fallen 
backwards, first struck the ground with the tuber- 
osity of the occipital bone, and sustained in conse- 
quence a concussion of the brain, manifested by 
insensibility and total unconsciousness of eight or 
ten hours. Being a diligent student of medicine, 
he continued his professional pursuits the following 
day, and without interruption for six weeks, during 
which time he took no further notice of the occur- 
rence. The general emaciation and failure of the 
sexual function were first perceived in little more 
than a week after the injury.^ Dr. Gall mentions 
that at Vienna he was consulted by two officers who 
had become impotent in consequence of blows from 
fire-arms which had grazed the napes of their 
necks-t 

When impotency depends on an injury of the 
head, the prospect of relief is in general far from 
promising. The event itself is one of the last to be 
detected, and is rarely perceived till all remedial 
treatment for the injury has ceased, and the patient 
is in progress of recovery. In some instances it is 
first announced by the visible wasting of the testes. 
When otherwise, however, the surgeon must not 
despair of the patient regaining his sexual powers 

* The Lancet, August 28, 1841, p. 784. 

t On the Functions of the Cerebellum, tr. by Combe, p. 46. 



DISORDERS OF THE TESTIS. 421 

as the other effects of the injury disappear. Thus 
one of the officers mentioned by Gall recovered by 
degrees the generative faculty, married, and became 
the father of several children. Purgation, followed 
by a slight alterative course of blue pill, effected a 
complete and speedy cure in Dr. Smyth's patient, 
after change of air and other hygienic measures 
had been tried in vain : as the gums became tender 
the patient began to recover flesh, and to experience 
a return of the procreative power. In the case of 
the patient injured on the railroad, the function 
was only partially restored. The treatment required 
in these cases would chiefly be such as would be 
adapted to remove the other symptoms of cerebral 
mischief If aphrodisiac medicines are used, they 
must be given with great caution. Electro-galvan- 
ism, applied from the occiput along the spine, might 
also prove of service. 

The reader will recollect the singular case of 
arrest of the developement of the testis related 
at page 120, in which the organs acquired their 
normal size and assumed their functions at an 
unusually late period of life, as the dormant pas- 
sions were aroused by a particular attachment. 
No doubt some men are less susceptible to the in- 
fluence of the female sex than usual ; and in such 
persons, until a suitable impression is made, and 
the instinct is excited, the sexual organs may re- 
main long inactive, and in abeyance. There are 
well recorded instances of men, and of persons too 
of great intellectual attainments, who, though to 
all appearance perfectly formed, have not only 



422 SYMPATHETIC AND FUNCTIONAL 

passed a life of absolute chastity, but have never even 
evinced the slightest disposition for sexual enjoy- 
ment. In the figurative language of Sir A. Cooper, 
" To such persons a Venus might display her 
charms, and on such her son might exhaust his 
quiver, in vain. No genial spring is here, no 
blooming summer, or fruitful autumn ; but all is 
winter — a dreary, desolate, and barren winter — 
in which the springs of life are frozen up, and the 
animal propensities destroyed." It is difficult to 
account for such cold indifference ; but we may 
suppose that, in some instances, that particular 
part of the brain which is the seat of the procreative 
function has been but little or imperfectly deve- 
loped. The several facts stated in this work fully 
justify the inference that the functions of the testes 
may remain unexercised, and that impotence may 
ensue from a cerebral defect, or from the absence 
of the usual stimulus derived from the sensorium ; 
and though more often occurring in idiots, I per- 
ceive no reason why such a fault should not exist 
in a brain otherwise in a high state of perfection. 
This constitutional and congenital form of impo- 
tency is sometimes, but not always, accompanied 
with arrest in the developement of the sexual organs, 
and an effeminate appearance and frame of body. 
Impotency of a temporary nature may be the effect 
of violent emotions of the mind, as mental affliction, 
anxiety, and rage ; indeed any impulse sufficiently 
intense to absorb the attention to the exclusion of 
the sexual passion will extinguish desire, and arrest 
the secretion of the testes. When, however, the 



DISORDERS OF THE TESTIS. 423 

emotion subsides, and the mind becomes tranquil- 
lized, the generative instinct may again be incited 
to action. Disgust, also, is sometimes a cause of 
sexual incapacity. Thus men, at other times 
competent to the act, have remained impotent in 
the company of certain women, owing to a natural 
aversion, or the uninviting person of their com- 
panion. For such cases of relative irnpotency the 
remedy is obvious. 

Not an unfrequent cause of a failure in the ex- 
ercise of the reproductive powers is want of self- 
confidence, — excessive apprehension of inability to 
perform well the duty of the sex. When persons 
are so timid and diffident as to entertain these 
groundless fears, it may be long before success 
attends their efforts, every failure adding to the 
evil by diminishing the reliance upon their powers. 
Mr. Hunter has treated this kind of impotency 
depending on the mind with his accustomed sa- 
gacity, and has related the following case. — He 
was consulted by a gentleman who had lost his 
powers in this way. The patient was subject 
to erections, accompanied with desire ; but from 
doubt, or fear, or the want of success, was unable 
to copulate with a particular female. Mr. Hunter 
told him that he might be cured if he could per- 
fectly rely on his own power of self-denial. He 
was then recommended to go to bed to this woman; 
but first to promise himself that he would not have 
any connexion with her for six nights, let his in- 
clinations and powers be what they would, which 
he engaged to do. This resolution produced such 



424 SYMPATHETIC AND FUNCTIONAL 

a total alteration in the state of his mind, that the 
power soon took place ; for instead of going to bed 
with the fear of inability, he went with fears that he 
should be possessed with too much desire, too much 
power, so as to become uneasy to him, which really 
happened ; for he would have been happy to have 
shortened the time : and when he had once broken 
the spell, the mind and powers went on together, 
his mind never returning to its former state.^ 
Modes of varying this advice in the case of persons | 
recently married, who may be affected with this 
form of impotency, will readily occur to the prac- 
titioner. Thus some mild tonic may be prescribed, 
and the patient be directed to abstain from inter- 
course while under treatment, and the surgeon may 
rest satisfied that not many days will pass over 
before nature asserts her empire. These cases 
must on no account be lightly treated. The situ- 
ation of the patient is often one of great distress 
of mind, and much relief may be afforded by the 
surgeon calmly reasoning with him on the subject 
of his complaint. He may be told that his case is 
not uncommon ; the true cause of failure may be 
pointed out ; and he may be confidently assured of 
the groundless character of his fears, and of the 
influence of his doubts and apprehensions in pre- 
venting him from fulfilling his desires. Kind and 
confidential advice of this nature, by encouraging 
the patient, will do more in effecting a cure than 
any sort of medical treatment or stimulating me- 
dicines. 

* Treatise on the Venereal Disease, 4to. p. 203. 



DISORDERS OF THE TESTIS. 425 

Diseases which destroy the substance or pro- 
duce wasting of the testis necessarily prevent its 
secreting. The functions, however, of this gland 
are not very readily impaired by disease ; and so 
long as a small part remains entire, the organ may 
be fitted to perform its office sufficiently for the 
end destined by nature. When the testis is to a 
great extent disorganized by the effusion of tuber- 
cular matter or lymph, and forms an open fungoid 
sore, secretion may still go on under excitement, 
as is evinced by the stiffened state of the dressings, 
and a microscopic examination of the discharge. 
This fact shows the importance of the surgeon 
striving to save the testis when mutilated either 
by accident or disease. In double hydrocele we 
know that the functions of the testes may still be 
performed. In inflammatory affections of the epi- 
didymis and vas deferens, it is very rarely that the 
matter effused amongst the convolutions of the 
duct obstructs the tube through which the semen 
has to pass, which is in a great degree owing to 
the absence of a fibrous envelope, and the yielding 
nature of the serous membrane by which it is in- 
vested ; whereas after inflammation of the body of 
the testis, wasting and disorganization are not un- 
common. In cases of congenital deficiency of the 
vas deferens, — in others in which this canal or the 
ducts of the epididymis are obstructed by tubercu- 
lar matter formed in their interior, or by deposits 
or tumours of any other kind, however sound may 
be the substance of the testis, the course of its 
secretion must necessarily be arrested, and the 

54 



426 SYMPATHETIC AND FUNCTIONAL 

organ thereby rendered useless. Severe varicocele 
tends gradually to impair the nutrition and di- 
minish the secreting powers of the testis. On the 
influence of detention of these organs in the abdo- 
men and in the groin external to the cavity on the 
sexual functions, I have fully expressed my opinion 
in Chap. I. Sect. 3, Certain affections, as carci- 
noma and the cystic disease, generally extend until 
the glandular structure is wholly destroyed. It is 
seldom, however, that both sides are affected, or 
that both testes are disorganized by disease ; and 
the remaining one, if sound and well developed, is 
fully sufficient for the purpose of reproduction. 
The same holds good when one testis has been 
removed by operation ; but when both are extir- 
pated or destroyed the patient becomes absolutely 
and permanently impotent. The question has 
been raised, and was at one time much discussed 
in Germany, whether a person castrated after ar- 
riving at the age of puberty may not retain the 
power of procreating for a certain period after- 
wards. The following case bearing on the point is 
recorded by Sir A. Cooper. — A man had one of 
his testes removed in 1799. In June, 1801, the 
other testis was removed by Sir A. Cooper in Guy's 
Hospital on account of a chronic abscess. He had 
been married prior to the loss of one testis. Four 
days after the second operation it was found that 
he had had during the night an emission, which 
appeared upon his linen. After he had recovered 
and quitted the hospital Sir A. Cooper repeatedly 
visited him for many years. For nearly the first 



DISORDERS OF THE TESTIS. 427 

twelve months he stated that he had emissions in 
coitu, or that he had the sensations of emission. 
That then he had erections and coitus at distant 
intervals, but without the sensations of emission. 
After two years he had erections very rarely and 
very imperfectly, and they generally immediately 
ceased under an attempt at coitus. Ten years 
after the operation he said he had during the past 
year been once connected. In 1829 he visited Sir 
A. Cooper, because he was a severe sufferer from 
piles. He then stated that for years he had seldom 
any erection, and then that it was imperfect; that 
he had no emissions from the first year of the 
operation ; that he had for many years only a few 
times attempted coitus, but unsuccessfully ; that 
he had once or twice dreams of desire, and a sen- 
sation of emission^ but without the slightest ap- 
pearance of it. The penis was shrivelled and 
wasted. He shaved once a week, and sometimes 
twice. His voice, naturally rather feeble, remained 
as at the time of the operation."^ Mr. Wilson per- 
formed the operation of double castration on a 
married man for carcinomatous disease of the tes- 
ticles. The wounds cicatrized in little more than 
a month, and he survived the operation two years. 
He assured Mr. Wilson that after the removal of 
the testicles he had occasional erections, not unac- 
companied with desire, and which, when as a mar- 
ried man he indulged, were attended with the usual 
paroxysm and emission of some fluid.t 

* Lib. cit. p. 53. 

t Lectures on the Urinary and Genital Organs, p. 133. 



428 SYMPATHETIC AND FUNCTIONAL 

In determining the question alluded to, we must 
not confound the power to copulate with that of 
procreation. It has been seen that the loss of the 
testes so affects the brain as completely to extin- 
guish the sexual instinct ; but this is an effect 
which, as is clearly shown by Sir A. Cooper's case, 
is not immediate, but takes place gradually ; hence 
we must admit that the castrated individual may 
experience desire, have erections, accomplish the 
coitus, and emit fluid for several weeks after re- 
covery from the operation. But the fluid which is 
essential for the propagation of the species is the 
secretion of the testes, none of which can of course 
be elaborated after the removal of the two glands. 
The question then resolves itself into this — how 
long may the seminal fluid already formed remain 
in the excretory ducts and vesiculae seminales in a 
condition to impregnate the female ? Much, of 
course, must depend on the state of the testis 
or testes at the period of the operation. If the 
gland last removed were thoroughly disorganized, 
taking into account the period previous to the 
operation since which the organ could have been 
in a condition to secrete, and the time occupied in 
the healing of the wound, which, together, cannot 
be estimated at less than eight or nine weeks, we 
may decide that in such a case the castrated patient 
would be unable to reproduce ; since in the nu- 
merous examinations which I have made of the 
fluid taken from the vesiculoe seminales and vasa 
deferentia of hospital patients who have died of 
various diseases, I have never found spermatozoa 



DISORDERS OF THE TESTIS. 429 

in them at a later period than seven weeks after 
their admission, or after they had possessed the 
opportunity of having sexual intercourse. In a 
case, however, in which the testes were sound and 
capable of secretion at the time of castration, it 
must be concluded that a sufficiency of the sper- 
matic fluid may remain in the excretory ducts 
and vesiculae for two or three weeks after recovery 
from the operation in the usual period, so as to 
allow of the possibility of impregnation, improbable 
as such an occurrence must undoubtedly be re- 
garded. 

An attack of apoplexy often permanently extin- 
guishes all desire as well as capacity for sexual 
enjoyment. Diseases and injuries of the spinal 
cord, producing paraplegia, have little effect on 
the testes, but destroy the power to copulate. In 
the chapter on Atrophy (page 118), I have given 
two instances of wasting of the testicles succeeding 
an injury to the spine ; but such is a rare result of 
this accident. In general, desire remains, the seat 
of the instinct being unaiTected ; and I suspect 
that in the cases alluded to, in which wasting 
took place, the injury affected other parts besides 
the spinal cord. M. Brachet has recorded the 
following curious case : — A soldier after several 
years' service experienced, in 1814 and 1815, rheu- 
matic pains, particularly in the lumbar region. 
In 1816 he had a fall from his horse. By degrees 
the lower extremities and inferior part of the 
abdomen became completely paralysed. For eight 
years the paralysis remained stationary. Whilst 



430 SYMPATHETIC AND FUNCTIONAL 

in this state he had two children. The spermatic 
fluid was secreted, erection took place, and ejacu- 
lation followed ; but " sans secousse et sans sensa- 
tion voluptueuse."* We must suppose that in this 
case, although the sensibility of the penis was de- 
stroyed, the connexion between the brain and testes 
was still maintained by the sympathetic system, 
which communicated the necessary influence ; and 
that their functions were, accordingly, as little dis- 
turbed by the affection of the medulla spinalis 
as are those of the important organs of the abdo- 
men in the same disease.t But, notwithstanding 
the success of this old soldier, there are few in a 
state of paraplegia who would not find themselves 

* Recherches Experimentales sur le Systeme Nerveux, 2d edit, 
p. 280. 

f M. Brachet performed the following experiments. — Having made 
sure that a cat a year old had covered several times a female cat with 
which he was shut up during the day, M. B. divided his spinal marrow 
between the third and fourth lumbar vertebres. All behind was para- 
lysed, the rectum and bladder equally so. He kept the animal three 
days ; when on examining the genital organs, he found them healthy, 
and the vesiculse seminales full of semen. This experiment was re- 
peated three times with the same result. The next is given in the 
words of the experimenter : " Sur un chat de dix mois, je fis la section 
de la moelle spinale dans la region lombaire. Comme la paralysie du 
train derriere mettait cet animal dans I'impossibilite d'executer les 
mancEuvres du coit, j'y fis suppleer par une sorte de masturbation. II 
fallut plus de terns, mais elle finit par determiner une ejaculation. 
Vingt-quatre heures apres, je fis repeter la meme manoeuvre ; et une 
nouvelle ejaculation eutlieu; je la fis encore repeter le lendemain 
avec le meme resultat." (Lib. cit. pp. 289-291.) These experiments, 
though interesting, as showing that the functions of the testes may be 
carried on in paraplegia without sensation or any influence derived 
from the brain through the spinal cord, do not, as Brachet supposed, 
prove that the secretion of sperm is altogether independent of the in- 
fluence of the spinal system. 



DISORDERS OF THE TESTIS. 431 

physically incapacitated. The nux-vomica which 
would be adapted to relieve the paralytic symptoms 
would likewise tend to restore the sexual powers. 
My colleague, Dr. Pereira, states that nux-vomica 
has been used as a remedy against impotence by 
Trousseau, who found it successful both in males 
and females. In some cases, however, its good 
effects were observed only while the patients were 
taking the medicine. A young man, twenty-five 
years of age, of an athletic constitution, who had 
been married for eighteen months without having 
any other than almost fraternal communications 
with his wife, acquired his virility under the use 
of nux-vomica, though he again lost it soon after 
leaving off its employment.* We might expect 
benefit too in these paralytic cases from electro- 
galvanism, so applied as to stimulate the nerves 
from the loins to the testes. 

Some error has prevailed respecting the effects 
of chronic diseases in impairing the functions of 
the testis. Thus consumptive individuals are sup- 
posed to be more than ordinarily addicted to sexual 
pleasure ; and it has been stated that they have 
retained the power and propensity to gratify it up 
to the very day of death. Louis made careful 
inquiries in reference to this point, and found in 
every instance that the tendency to sexual inter- 
course declined with the increase of general weak- 
ness and other symptoms, almost exactly as is the 
case with individuals labouring under any other 

* Elements of Materia Medica, 2cl edit. vol. ii. p. 1305. 



432 SYMPATHETIC AND FUNCTIONAL 

affection * The accuracy of this statement is con- 
firmed by my own observations and inquiries. I 
examined the testes of four persons who had died 
of pulmonary consumption, and found that they 
were all below the average weight and size of 
those of healthy adults. In the testes taken from 
the bodies of twelve phthisical patients examined 
in the London Hospital, no spermatozoa could be 
detected in the fluid obtained from the substance 
of the gland and epididymis. In several of these 
cases, the contents of the vesiculae seminales were 
likewise examined, and found destitute of sperma- 
tozoa.t Rayer has also remarked that the vesiculae 
of phthisical patients afford few or none of these 
bodies.^ A fit of dyspepsia is an occasional cause 
of temporary loss of virile power. A gentleman, 
after a separation of many weeks from his wife, on 
his return was much alarmed by finding himself 
incapacitated. On inquiry, it appeared that he 
had dined imprudently, and had suffered from indi- 
gestion and heartburn during the night. Virility 
is more permanently affected by organic disease of 
the abdominal viscera ; but there are few com- 
plaints which have greater influence in impairing 
the generative functions than those of the kidneys. 
It has been noticed in men subject to deposits of 

* Pathological Researches on Phthisis, tr. by Cowan, p. 224. 

f Dr. Davy examined microscopically the fluid taken from the 
divided substance of the testis of twelve persons who died of phthisis, 
but in no instance discovered spermatozoa ; but he found them in 
several instances either in the vesicula3 seminales or vasa deferentia; 
Edinb. Medical and Surgical Journal, July, 1838, p. 1. 

I Archives Genera] es de Medecine, Aout, 1842, p. 487. 



DISORDERS OF THE TESTIS. 433 

the oxalate of lime, that the sexual power is gene- 
rally deficient, and often absent."^ A middle-aged 
man, who had led rather a dissipated life, and was 
subject to pains in the loins and deposits of the 
phosphates, assured me that when suffering from 
these attacks he lost all desire for connexion, and 
was quite unable to indulge in it. Other instances 
of defective power in persons subject to lumbar 
pains and urinary deposits have come under my 
observation. In diabetes, and Bright's disease of 
the kidney, the reproductive organs are much de- 
bilitated, and often quite inactive. Again, diuretics, 
or remedies that excite the secretions of the kid- 
neys, as the nitrate of potash, digitalis, &c., are 
found to act as anaphrodisiacs. The testes of 
persons who die of chronic lingering diseases are 
almost invariably soft and inelastic. When incised, 
their internal structure seems to contain but few 
blood-vessels, is pale, apparently shrunk and dry, 
and the little fluid that can be squeezed from it is 
destitute of spermatozoa. 

Abuse of the sexual organs is a frequent cause of 
impotency, and of impotency the most difficult to 
treat and remove ; as moral equally with medical 
treatment is required, the mind being frequently 
more at fault than the body, and the surgeon find- 
ing it as necessary to urge the duty and importance 
of abstinence and self-control as to prescribe for 
the patient's health. Persons who indulge to excess 
sometimes become suddenly impotent, and a con- 

* Dr. Bird. Medical dazette, vol. xxx. p. 750. 
55 



454 SYMPATHETIC AND FUNCTIONAL 

siderable period of rest may elapse before the organs 
are capable of resuming their functions. Such oc- 
currences are not unfrequent shortly after mar- 
riage. Addiction to sexual pleasure in early life 
often entails a permanent loss of power in middle 
age, at a period when most men still retain it in 
full vigour. This is often experienced in the des- 
potic countries of the East. M. Volney * in his 
Travels through Asia Minor, mentions that the 
people of rank in that country, who can afford the 
expense of a harem, often complain of impotency 
at the early age of thirty. Mr. Russell of Edin- 
burgh, in some excellent observations on this sub- 
ject, remarks that matters are not so bad in this 
country, though it is a well-known fact that young 
men of fashion, who indulge their amorous propen- 
sities at an early age, lose the power of procreating 
sooner than the more continent, and are familiarly 
distinguished by the quaint appellation of " God's 
geldings."t Too great indulgence of the sexual 
appetite is productive, however, of other effects 
besides premature impotency : as every practical 
surgeon is aware, it tends to derange the digestive 
functions, and to weaken the physical and mental 
powers. Sexual excesses are likewise a fertile 
source of the diseases of the testis: persons affected 
with chronic inflammation and other disorders of 
the gland frequently, and I believe with justice, 
refer their complaints to an unrestricted indulgence 



* Voyage en Syrie et en Egypte, torn. ii. p. 444. 
f Observations on the Testicles, p. 35. 



DISORDERS OF THE TE&TIS, 435 

of their passions. I suspect, too, that these ex- 
cesses, if long continued, are very apt to lay the 
foundation of disease in the kidneys. A gentleman, 
who when young had been much addicted to the 
society of women, now invariably suffers from 
pains in the loins, and alkaline urine, after inter- 
course with the sex. 

One of the most common results of inordinate 
excitement of the genital organs is an excessive 
secretion of the spermatic fluid, evinced by in- 
voluntary seminal emissions. For obvious reasons 
I shall not enter minutely into the history of these 
cases, but must refer the reader to the work of 
Professor Lallemand of Montpellier,'^ in which the 
subject is fully treated of, and numerous cases are 
detailed. The complaint comes on very gradually. 
It commences by a precipitate emission of semen 
either in coition or during lascivious dreams. 
There exists a state of morbid irritability of the 
organs. The emissions consequently are prema- 
ture, and without force, and the erections slight 
and incomplete, and soon subside. As the affection 
increases the emissions become more frequent and 
more readily excited, and are induced merely by 

* Des Pertes Seminales Involontaires. Mr. Philipps has lately 
published some cases of this distressing affection in the 31st volume of 
the Medical Gazette. As this sheet is passing through the press I have 
received the British and Foreign Medical Review for April, 1843, 
which contains an instructive article on " involuntary spermatic dis- 
charges," that cannot fail to be read by the profession with much 
interest. I fully concur in the strictures of the writer on the exag- 
gerated views and bad taste exhibited by Lallemand, especially in the 
concluding volume of his work. 



436 SYMPATHETIC AND FUNCTIONAL 

erotic ideas or the least contact or titillation, and 
take place without erection and without pleasure. 
In this weak and susceptible condition of the organs 
pollutions are liable to occur both day and night, 
constituting a state of passive spermatorrhoea, which 
often lasts for many months, gradually undermining 
the health. The patient becomes thin, pale, and 
feeble ; has impaired vision, and a sickly languid 
look ; suffers pains in the head and back ; is hypo- 
chondriacal and apathetic, and totally unfitted for 
active bodily or mental occupation. He often expe- 
riences uneasy sensations in the testicles, which are 
soft, and hang low. The scrotum is pendulous and 
lax, and the spermatic veins are commonly large 
and varicose. His symptoms are aggravated after 
each emission, which is usually followed by a pain- 
ful sense of fatigue, and malaise, that last many 
hours. 

This obstinate and distressing complaint may be 
produced either by excessive indulgence in sexual 
intercourse, or by long-continued and frequent self- 
abuse, those who give way to these vicious habits 
being little av/are of the evils they engender. They 
occasionally acquire a complete m.astery over the 
reason and will. In some cases not even the 
strongest self-control can repress the disposition 
to abuse ; and persons fully aware of the evil 
results, and actually dreading the consequences, 
are unable to restrain their fatal desires. In these 
cases there is a peculiar morbid condition of the 
nervous system. Indeed, the debilitating and ener- 
vating effects of this affection are far greater than 



DISORDERS OF THE TESTIS. 437 

would be occasioned merely by a drain of the 
amount of the fluid emitted, which is to be ascribed 
to the nervous exhaustion especially attending the 
reproductive function. The patient's mind is con- 
stantly absorbed with his sufferings ; he jfinds 
great difficulty in abstracting his attention from 
them, and occupying himself with other matters, 
and eagerly peruses any thing relating to his com- 
plaint ; a circumstance well known to the empirical 
authors, who are constantly advertising their works 
on the subject. The condition of these persons is 
melancholy enough. Aware of the abhorrence with 
which their practices are regarded, they hesitate to 
consult the regular practitioner, and fly for relief 
to ignorant but artful quacks, by whom their pe- 
cuniary resources are drained, for which they only 
meet in return with bitter disappointment. Such 
is the heavy penalty often paid by man for gross 
indulgence in sensuality — a degraded nature and 
a ruined constitution embittering the best days of 
his existence, and sometimes leading to insanity or 
suicide. 

The matter emitted in these cases is thin, and 
more liquid than healthy semen ; but that it is 
really spermatic is proved by the spermatozoa 
which it is found to contain. Lallemand, who 
carefully examined the fluid voided in all stages of 
the complaint, found the zoosperms less abundant, 
and less developed and lively, in proportion to tlie 
severity of the disease, until at length in very 
advanced cases they almost entirely disappeared."^ 

* Lib. cit. torn. ii. p. 407. 



438 SYMPATHETIC AND FUNCTIONAL 

The discharge is largely diluted with the secretions 
of the vesicalce seminales and prostate ; and in bad 
cases of the complaint the fluid emitted consists 
almost entirely of the latter, mixed with purulent 
matter. Occasionally the spermatic fluid, and even 
the prostatic secretion, pass into the bladder and 
mix with the urine, with which they are voided. 
Directions have been given for distinguishing the 
semen under these circumstances, but they are not 
to be depended on ; and the only sure mode of 
ascertaining the existence of semen in the urine is 
a microscopic examination of the fluid, in order to 
detect the spermatozoa. 

Although this complaint is usually considered 
and treated as a functional derangement, there are 
few cases in which the parts remain even in the 
early stage in a perfectly sound state. It will be 
found that the patient usually experiences a fre- 
quent desire to void his urine ; that the evacuation 
is attended with scalding ; that he frequently feels 
pain and heat in the prostatic part of the urethra ; 
and that if a bougie or catheter be introduced as 
far as this portion of the canal in the most gentle 
manner, it causes a sharp pain, and sometimes vio- 
lent spasmodic contractions, the instrument being 
at the same time grasped in the canal. The pros- 
tatic and membranous parts of the urethra are 
indeed in a state of morbid irritation ; and I believe 
that the increased secretion of the testes, the hasty 
ejaculations, and inordinate desire for sexual in- 
dulgence or self-abuse very greatly depend on this 
diseased condition of the mucous membrane. Nor 



DISORDERS OF THE TESTIS. 439 

is it surprising, considering how much this part of 
the urethra is concerned in the functions of gene- 
ration, that a permanent state of disease should be 
produced by the frequent excitement of unnatural 
excess. Involuntary spermatic discharges have in 
some instances been induced by gonorrhoea af- 
fecting the prostatic part of the urethra. Their 
origin has also been ascribed to certain affections 
of the prepuce and of the rectum and skin ; but I 
have not met with any case of involuntary emissions 
occurring from these causes independently of local 
irritation in the urethra. Very few opportunities 
are afforded of making an anatomical examination 
of the parts affected, especially in the early stage 
of the complaint. Lallemand examined them in 
two very severe and complicated cases of the dis- 
ease, in which the patients laboured under symp- 
toms of cerebral congestion before death.* I also 
carefully dissected them in an aggravated case, in 
which the patient was comatose for several hours 
previous to dissolution. In all three the morbid ap- 
pearances were of the same character. The mucous 
membrane at the prostatic part of the urethra was 
swollen and injected. The prostate was nearly de- 
stroyed, and converted into a multilocular abscess, 
or a number of alveolae or cells, communicating with 
each other ; and the diseased mucous membrane 
covering it was riddled with holes, formed by a con- 
siderable enlargement of the original orifices of the 
gland, through which pus or altered secretion freely 

* Lib. cit. t. i. p. 13, et seq. 



440 SYMPATHETIC AND FUNCTIONAL 

escaped on pressing the prostate. As Lallemand 
aptly remarks, the membrane at this part covers 
the multilocalar cavity of the prostate, much in the 
same way as the cribriform plate of the ethmoid bone 
covers the nasal fossa in the dried skull. One or 
both vesiculae seminales were infiltrated with pus, 
and their walls thickened by inflammation. The 
orifices of the ejaculatory canals were enlarged and 
abraded. When the prostate is much afifected, 
pain is occasioned by pressing on it through the 
rectum, and there is usually a discharge from the 
urethra when the patient is at stool. In inveterate 
cases of the disease, the mucous membrane of the 
bladder becomes inflamed, and secretes a ropy 
mucus. The urine is ammoniacal, and the disease 
extends along the ureters to the kidneys. 

The irritation attending the morbid condition of 
the mucous membrane of the prostatic part of the 
urethra, tends in a very material degree to excite 
both the excessive seminal discharge and the secre- 
tions of the prostate, and to produce that morbid 
craving for indulgence and abuse which persons 
who have brought themselves to this state find so 
difficult to repress and resist. It is well known 
that any irritation at the orifice of an excretory 
duct usually acts as a stimulus to the secretions of 
the gland. Thus hurtful matter in the duodenum 
produces a flow of bile ; and a foreign body in the 
conjunctiva, as an inverted eyelash, a discharge of 
tears. So it is with the testis when irritation 
exists at the orifices of their excretory ducts. The 
disorder at this part, moreover, appears to react on 



DISORDERS OF THE TESTIS. 441 

the brain, and to become in part the cause of the 
patient's mind being constantly occupied with sub- 
jects of sexual excitement, and of his indifference 
and apathy in respect to other matters.* So that 
the local disease induced by abuse powerfully aids 
in perpetuating the mischief, and, judging from the 
experience which I have had in these cases, is the 
object to which our treatment should be first direct- 
ed. Certainly in confirmed cases, until the nK)rbid 
condition of the mucous membrane of the urethra 
is corrected, we can scarcely hope to relieve the 
seminal emissions, or to recruit the patient's health 
and strength ; and when it is removed there is 
far less difficulty in inducing him to abandon his 
injurious habits, and in im.proving his general con- 
dition by other treatment. In some persons there 
appears to be a predisposition to this complaint, 
which is indicated by feeble sexual powers, and 
irritability of the bladder and incontinency of urine 
in early life. 

* This is a truth, I fear, not sufficiently impressed on the minds of 
medical men. One would be loth to offer any apolog-y for the vicious 
habits and indulgences to which, it is well known, old men are occa- 
sionally addicted, — a melancholy example of the kind in the higher 
ranks in life having lately been brought under public notice. I cannot 
but think, however, that in many instances these cases are not unde- 
servmg of professional sympathy, and that the erotic longings which 
sometimes continue to distress the aged long after the period at which 
in the course of nature they should have ceased depend as much on 
physical infirmity as mental depravity, the former inciting and pro- 
ducing the morbid desires. If these propensities were regarded and 
treated as symptoms of disease (and that they frequently occur in 
connexion with affections of the urinary passages is well known to 
practical surgeons), I believe they would oflen subside, and the dis- 
tressing results to which they lead would be altogether avoided. 

m 



442 SYMPATHETIC AND FUNCTIONAL 

It is necessary to remark, that in persons whose 
constitutions are suffering from frequent seminal 
emissions, it is not always easy to ascertain the real 
cause of impaired health. Either from not suspect- 
ing it, or unwillingness to confess, patients are apt 
to refer their complaints to any thing but the true 
cause. They complain of indigestion, palpitations, 
pains in the head, &c., but neglect to mention the 
emissions ; so that much tact and cautious inquiry 
are often necessary in order to discover the nature 
of the malady with which they are afflicted. 

In most cases of this disease the local application 
of the nitrate of silver is by far the most effectual 
means of restoring the prostatic part of the urethra 
to a sound state. It allays the morbid sensibility 
and corrects the altered condition of the membrane 
and orifices of the ejaculatory canals, and thus ar- 
rests the excessive secretions of the testicles and 
prostate. The nitrate of silver, when applied to the 
diseased part of the urethra, appears to act on the 
seminal vesicles and follicles of the prostate gland, 
very much in the same way as a stimulating appli- 
cation to the conjunctiva of the eye relieves amor- 
bid condition of the membrane of the nasal sac or 
duct by being absorbed at the puncta lachrymalia. 
The dissolved caustic entering at the enlarged ori' 
fices at the sides of the veru montanum thu& reaches 
the interior of these glands. The beneficial effects 
of the nitrate of silver in this affection appear to 
have been known to Sir E. Home, who, in his work 
on Strictures,^ has recorded two cases of seminal 

'^' Vol, ii. p. 427. 



DISORDERS OF THE TESTIS. 44c5 

emissions consequent upon onanism, which were 
much relieved by the application of the armed 
bougie. His mode, however, of using this remedy 
w^as very defective ; and the plan of treatment does 
not seem to have been followed by other surgeons 
in these particular cases. It is to Lallemand that 
we are indebted both for showing the great value 
of the caustic treatment of this complaint, and for 
devising an improved instrument for making the 
application. In January, 1839, some observations 
were published by me in the Medical Gazette* on 
the employment of the nitrate of silver in certain 
kinds of stricture, and in the affection termed " irri- 
table urethra," in which I gave a description of 
Lallemand's instrument, and pointed out its supe- 
riority over other modes of applying the caustic. 
Shortly afterwards a gentleman partly educated to 
the profession, who contemplated proceeding to 
Montpellier to place himself under the care of Lal- 
lemand for the cure of involuntary seminal emissions 
attended with the most distressing symptoms, hav- 
ing seen the paper alluded to, called to ask me to 
undertake the treatment of his case on Lallemand's 
plan. I did so ; and the success which followed 
the use of the lunar caustic in this instance induced 
me to employ the same remedy in other cases which 
came under my care, both in public and private 
practice ; and a considerable share of experience 
now induces me to speak w^ith confidence of its 
beneficial effects. 

* Vol. xxiii. p. 596. 



444 



SYMPATHETIC AND FUNCTIONAL 




%> 



Tig. 2. 



Lallemand's instrument con- 
sists of a slightly-curved platina 
canule or tube, rather smaller 
than a middle-sized catheter 
{Fig. 1. A), through which plays 
a caustic holder, having at its 
further extremity a narrow 
groove, eleven lines in length 
(B), for the purpose of receiving 
the caustic. After filling the 
groove with the nitrate of silver i| 
by fusing it over a spirit lamp, 
the caustic becomes so securely 
fixed that there is no danger of 
its escaping. At the other end 
there is a sliding screw or stop 
(C), by which means the appli- 
cation of the caustic may be 
limited to any extent less than 
the length of the groove which 
contains it. In employing this 
instrument I proceed as follows : 
— Having regulated the caustic 
holder so as to admit of nearly 
the whole of the groove being 
uncovered, and having closed 
the instrument so as to conceal 
the caustic {Fig, 2), I introduce 
it well oiled as far as the pros- 
tatic part of the urethra, its 
arrival there being easily ascer- 
tained by the pain experienced by the patient, and 



11 



DISORDERS OF THE TESTIS. 445 

by my being able, after the instrument is depressed 
and has passed the triangular ligament, to carry it 
freely onwards.^ I then thrust forwards the caustic 
holder, and after passing it once or twice backwards 
and forwards instantly close the apparatus, and 
then withdraw it. An one time I used to employ a 
straight instrument, which may generally be intro- 
duced without difficulty ; but one slightly curved 
is rather more convenient. When applied in 
the transient manner I have just described, the 
caustic occasions a sharp smarting sensation, which 
sometimes causes the patient to faint ; but it sub- 
sides in from ten minutes to half an hour. On 
making water afterwards the patient experiences 
scalding, and usually passes a little blood and 
purulent discharge, which continue for twenty- 
four or thirty-six hours, and then gradually cease. 
If much pain or retention of urine should re- 
sult from the application, it may be relieved by 
leeches to the perineum, the hip-bath, and opiate 
suppositories or injections. I have never found the 
caustic produce so much haemorrhage and such 
severe symptoms as are described by Lallemand 
occasionally to arise from it, which I attribute to 
the more gentle manner in which the application is 
made. 

In general, the emissions cease entirely after one 

* At first T used to pass a wax bougie down to the prostatic por- 
tion of the canal, in order to ascertain its distance from the meatus, 
that I might be exact in cauterising the particular part affected, but 
after a little practice in the use of the instrument I found this unne- 
cessary. 



446 SYMPATHETIC AND FUNCTIONAL 

or two applications of the caustic, though it is 
sometimes necessary to make three or four before 
they are completely arrested. Opium or henbane 
may at the same time be given at night to procure 
rest and allay irritation, and the cold douche may 
be daily applied to the pelvis and genitals. The 
determination of blood to the prostate and neigh- 
bouring parts may be restrained by an enema of 
cold spring water, administered by the patient be- 
fore rising in the morning, which also tends to 
relieve constipation. ' I have found that the Pulv, 
Cubebis, in small doses of from gr. xv. to gr. xxx. 
combined with the tincture of henbane, taken twice 
a day, by its influence on the urethra materially 
aids the cure of this affection. Indeed in very 
slight cases this remedy, and the occasional intro- 
duction of a catheter or bougie, are sufficient to 
correct the morbid condition and sensibility of 
the mucous membrane without the caustic. As 
the local affection subsides, we must have recourse 
to other remedies to improve the general health. 
Thus steel medicines, quinine, cold bathing, a nu- 
tritious but not stimulating diet, due regulation of 
the bowels, change of scene and exercise in an open 
pure air, and cheerful occupation, prove very bene- 
ficial in these cases. I have previously had occasion 
to notice the salutary influence of active bodily 
exercise in subduing the ardour of the sexual pas- 
sion. The same means, in moderation, are also effi- 
cacious in allaying the morbid excitement of which 
I am now treating. It need scarcely be added, that 
no method of treatment is likely to be successful or 



DISORDERS OF THE TESTIS. 447 

permanent, without the most rigid and persevering 
abstinence in respect to the exciting causes of the 
complaint. All subjects capable of exciting erotic 
ideas should therefore be strictly avoided ; and it 
must be recollected that a relapse is readily induced 
by the least imprudence or excess. Persons suffer- 
ing from involuntary seminal emissions are often 
recommended to marry. This advice is not only 
unsound, but actually injurious ; and if followed, 
which I believe rarely happens, would be a cause 
of much misery. Persons thus affected are by no 
means in a condition to enter the marriage state ; 
they are in fact impotent ; and nothing is more 
calculated to aggravate their complaints and impede 
recovery, than the excitements of the sex and fruit- 
less attempts at sexual indulgence. The indications 
afforded in these cases are, to arrest the debilitating 
discharges ; to obtain a period of rest during which 
the parts may recover their tone, the health may 
be reinstated, and the constitution fully invigorated. 
When this is effected, but not till then, marriage is 
desirable, as it takes away the temptation to solitary 
vice, and is favourable to regularity and moderation 
in the performance of the reproductive functions, 
and thus obviates the tendency to a relapse. 

Persons troubled with seminal emissions which 
no effort of the will can prevent their provoking, 
or which persist in spite of medical treatment, have 
in some instances been anxious for the removal of 
the testes, to get rid of a complaint so completely 
destructive to their health and happiness : and in- 
dividuals have even been known to perform the 



448 SYMPATHETIC AND FUNCTIONAL 



operation of castration on themselves in conse- 
quence."^ A short time since I received from a 
patient thus affected two letters urgently request- 
ing me to remove his right testicle, his left having 
been extirpated by a surgeon some time previously. 
This man refused to submit to any other treatment 
for his complaints, being impressed with the idea 
that this operation was the only remedy that could 
relieve him. He was a patient of my friend Mr. 
Avery, surgeon of the Charing Cross Hospital, who, 
as well as myself, was teased with repeated solicita- 
tions to castrate him.t This operation can scarcely 
be, in any case of involuntary seminal emissions, 
justifiable. Unless important organic changes have 
taken place in the genito-urinary organs, the affec- 
tion is certainly remediable by judicious treatment 
steadily pursued ; whilst the operation of castra- 
tion, even if effectual in relieving the symptoms, 
would leave the patient in a state of mutilation 
which might afterwards prove a source of the most 
bitter regret. I have been informed by a professional 
friend of a case in which double castration was 
performed, at the urgent request of the patient, on 
account of most distressing self-pollutions, that had 
a very lamentable result. The patient, a gentleman 
in the upper ranks of life, committed suicide ; and 
the surgeon, who had been rash enough to emas- 
culate him, was threatened by the patient's friends 

* Several cases of self-castration are related in Chap. III. Sect. 2. 

1 1 have recently been informed that a surgeon had been induced 
to perform the operation, and that the patient was well pleased with 
the result. 



S 



DISORDERS OF THE TESTIS. 449 

with an action at law for performing so unwarrant- 
able an operation. 

Solitary abuse is sometimes practised in infancy ; 
and in two cases which have come to my knowledge 
it occurred at the early age of between three and 
four years. The sexual organs were not prema- 
turely developed, but in one of them the child 
had passed a small calculus. The vice has been 
ascribed to the irritation produced by worms in the 
rectum ; but 1 fear it is more often induced by 
the foolish habits of children and their associates. 
Though little fluid is emitted, the practice is very 
injurious to the constitution by its effects on the 
nervous system, and prevents the developement of 
the sexual powers. As in the adult, it produces 
a morbid sensibility and condition of the urethra, 
which is also to be treated on the same principles. 

I have little to add to the observations already 
made respecting the treatment of the different 
forms of impotency. In several instances, whilst 
explaining the cause of the power being lost, I 
have suggested the remedies necessary for its re- 
establishment. Certain medicines, reputed to pos- 
sess the property of restoring the sexual functions, 
have been classed as aphrodisiacs; and some of 
them are said to be used, especially in the East, 
by the sensualist, to excite the organs when ex- 
hausted by satiety and excess. Some of them act 
on and stimulate the urinary apparatus, and thereby 
give a temporary power to the function of erection, 
but they produce little or no effect on the special 
sexual organs. They act much in the same way as 

57 



450 SYMPATHETIC AND FUNCTIONAL 

haemorrhoids, affections of the prostate, and calculi 
in the kidney or bladder, the irritation of which 
often determines blood to the penis, and causes 
morbid erections. Such appears to be the nature 
of the influence produced by the cantharides, the 
most common of this class of medicines, and the 
chief ingredient of quack remedies for impotency, 
There are, however, few cases of defective sexual ■ 
power in which the use of cantharides would be I 
proper. In many it would certainly be injurious, 
producing an unnatural excitement when repose is i 
most desired ; so that even if it enabled the patient 
to have connexion, its ultimate effects would rather ,. 
tend to render the impotency more permanently f' 
hopeless. Almost the only description of case in 
which I should be induced to recommend this 
remedy is an atonic state of the organs consequent ' 
on long disuse, in which, though the desires are 
strong,^ the erections are feeble, and take place with 
difficulty. In such case rnxx. of the Tinct. Can- 
tharidis, with the same quantity of the Tinct. Ferri 
Sesquichloridi, may be given twice or thrice a day. 
Bayle states that Leroy and Bouttatz experimented 
on themselves with phosphorus, and found that it 
produced strong excitement on the genital organs. 
The same was observed in animals to whom Leroy 
gave this remedy.* Phosphorus seems to act 
much in the same way as cantharides, irritating 
and stimulating the urinary organs, and determin- 
ing the blood to these parts, and no doubt its effects 

* Bibliotheque de Therapeutique, torn, ii, p. 124. 



DISORDERS OF THE TESTIS. 451 

would be equally injurious in many cases of im- 
potency. In the class of atonic cases alluded to 
above, we might hope for some benefit from the 
ergot of rye, which in man appears to act as a 
stimulus to the generative organs, as well as to the 
neighbouring parts; but further experience is re- 
quired of the effects of this remedy in cases of 
impotency. The aphrodisiac most wanted is one 
capable of stiaiulating the sexual organs, and ex- 
citing the secretion of the testes by its influence on 
the sensorium, or on that particular part which is 
the seat of the reproductive function. I know no 
remedy which possesses this power, except, perhaps, 
the Indian hemp, or Gunjah (^Cannabis Indica), 
It is well known that the use of this drug is in- 
dulged in by the inhabitants of certain countries, 
on account of the pleasurable excitement to which 
it gives rise. According to Dr. O'Shaughnessy of 
Calcutta,^ its effects, when given in small doses^ is 
to cause an increase in the fulness and frequency 
of the pulse, a glow on the surface of the body, re- 
markable increase of appetite, unequivocal aphro- 
disia, and great mental activity and cheerfulness ; 
and no headache, delirium, sickness, or other un- 
pleasant symptom followed its use. The dos^ re- 
ported to be capable of causing these effects is a 
quarter of a grain of the resinous extract, or half a 
drachm of the tincture, once or twice repeated, 



* On the Preparations of Indian Hemp, &c. Transactions of tlie 
Medical Society at Calcutta, 1839; and Provincial Medical Join-nal, 
Jan. 1843. 



452 CASTRATION. 

until the remedy produces its exhilarating influence 
on the system. 

I have lately made some experiments with the 
extract of hemp, obtained from Mr. Squire of Ox- 
ford Street, which is understood to be genuine ; 
but it certainly produced no marked aphrodisiac 
effects. I gave a gentleman five grains of it at a 
dose ; it produced a feeling of intoxication, dilata- 
tion of the pupils, and dizziness, but did not quicken 
the pulse : there was a feeling of desire, but no 
expression of power to indulge. I believe that 
its effects on the European constitution are in some 
degree different from those which it exerts on the 
Asiatic, and that in the former larger doses are 
required to obtain its influence. On the latter the 
concurring testimony of different observers leaves 
no room to doubt its aphrodisiac powers, and its 
general use by the inhabitants of the East for the 
purposes of erotic excitement. 



CHAPTER XVIII. 



CASTRATION. 

Castration, or the extirpation of the testis, is well 
known to be an operation of great antiquity, and 
was formerly one of the most common in surgery. 
Even at the present day it is frequently performed 
by the barbarous people of the East to deprive 



CASTRATION. 453 

their slaves of manhood ; but this cruel and un- 
christian practice is now rarely resorted to in 
Europe, except for the removal of disease, being 
uncommon even in Italy, where it was once fre- 
quently performed on account of its effects on the 
vocal organs. 

The diseases of the testis which may lead to the 
necessity for castration are the different forms of 
carcinoma, incurable strumous disease, tedious 
sinuses and fungoid growths consequent on in- 
flammation, cystic disease, and varicocele combined 
with severe neuralgia. The circumstances under 
which the operation is admissible in these various 
diseases have already been considered. 

Castration is an operation simple, easy of per- 
formance, and nearly free from danger ; but painful, 
owing to the large number of nerves and great sen- 
sibility of the parts incised. The surgeon should 
endeavour, therefore, to perform it with expe- 
dition. Before he commences the hair must be 
cleanly shaved off from the pubes and scrotum, or 
it will interfere with the plaister in the dressing 
of the wound. The only instruments required are 
a straight bistoury or large scalpel, a pair of for- 
ceps, tenaculum, and curved needles armed with 
ligatures. The patient is to recline upon a table 
of convenient height, and the operator is to place 
himself on the right side ; or he may seat himself 
between the patient's legs. An incision is to be 
made skin-deep from about half an inch below the 
external ring, along the front of the tumour to the 
bottom of the scrotum. The envelopes of the cord 



454 CASTRATION. 

and testis, the layers of thickened fasciee, and the 
cremaster muscle are then to be freely divided, 
nearly as high up as the abdominal ring. If this 
part of the operation be interrupted by bleeding 
from any of the branches of the external pudic 
artery, it will be well to secure them with ligatures. 
As soon as the spermatic cord is detached from the 
surrounding parts and fully exposed, it is to be 
grasped between the finger and thumb of an assist- 
ant to prevent its retraction within the inguinal 
canal after being divided, and it is then to be cut 
across by a single stroke of the knife. Some sur- 
geons are accustomed to secure the cord by passing 
a tenaculum or needle and ligature through it ; a 
plan which need only be adopted when it is neces- 
sary to divide the cord very high up, as in general 
the fingers of an assistant are sufficient for the 
purpose, and giv^ less pain and produce less dis- 
turbance of the parts than the other method. The 
arteries of the cord can now be secured ; or if the 
compression employed by the assistant be sufficient 
to check the haemorrhage, the surgeon may at once 
proceed to dissect the tumour from out of the scro- 
tum. This part of the operation may often be 
much facilitated by traction, so employed as to 
lacerate and detach the cellalar connexions of the 
diseased gland. In chronic cases, the cellular tissue 
of the scrotum is often too condensed and thickened 
to admit of being thus torn ; and in nearly all in- 
stances the dense adhesion between the lower part 
of the testis and the scrotum requires division with 
the knife. When the tumour is of large size, care 



CASTRATION. 455 

is necessary in detaching the testis from the scro- 
timi to avoid wounding the urethra and corpus 
cavernosum, and also the opposite gland, which 
should be drawn aside by an assistant. 

Many surgeons recommend that the testis should 
be detached from the scrotum before the division 
of the cord ; but, as Sir A. Cooper has remarked,"^ 
this obviously prolongs the time of the operation, 
and adds considerably to the sufferings of the pa- 
tient. On the other hand, when the cord is first 
divided, the testis is easily drawn forth from the 
scrotum by means of the cord itself, and the adhe- 
sions that may exist are cut or broken down with 
greater facility and rapidity than by any other 
mode. 

The bleeding mouth of the spermatic artery is 
soon found, and is to be secured separately by a 
silk ligature. The artery of the vas deferens must 
next be sought for near the duct, and also tied. 
This vessel is so small that it is not always ap- 
parent ; but the surgeon should endeavour to se- 
cure it, as it is sometimes the source of a trouble- 
some haemorrhage after the conclusion of the ope- 
ration. The bleeding vessels of the scrotum are 
next to be tied : if the tumour be large, or the 
disease of long standing, they are likely to be very 
numerous. In securing vessels in the loose cellular 
tissue of the scrotum and other parts much assist- 
ance may be derived, especially if the assistants be 
unaccustomed to operations, from the employment 

* Cyclopsedia of Surgery, art. Castration, vol. i. p. 704 



456 CASTRATION. 

of a clumsy-looking but very useful pair of forceps, 
with broad blades coming abruptly to a point, to slip 
the ligature on the vessel. The oozing of blood 
from many of the smaller vessels may be arrested 
by torsion, or bathing the parts with cold water. 

The ligatures attached to the cord being carried 
to the upper angle of the wound, the divided edges 
are to be brought together by two or three sutures 
or more, according to the length of the incision. 
Strips of plaister are not sufficient, as the natural 
contractility of the scrotum tends to separate and 
evert the edges of the wound. The closure of the 
wound is to be completed with narrow strips of 
adhesive plaister applied transversely, and the part 
is to be covered with a dossil of lint : the scrotum 
must afterwards be supported, and the dressings 
retained by a T bandage. When the patient re- 
turns to bed the parts must be kept cool by a 
cradle placed over the pelvis under the bed-clothes. 
The upper part of the wound often unites by the 
first intention ; but the lower usually heals by gra- 
nulation in from twenty to thirty days. 

There are a few circumstances of importance to 
be attended to in this apparently simple operation, 
and certain modifications are sometimes required. 
The operator should be careful to carry the first in- 
cision to the lowest part of the scrotum, as by this 
means he not only facilitates the detachment of the 
tumour, but afterwards prevents the bagging of 
matter in the scrotum, which is very liable to occur, 
and retard the healing process when this point is 
neglected. If the gland is of great size, or the skin 



CASTRATION. 457 

adherent to it or diseased, it will be advisable to 
remove a portion of the scrotum. Instead, there- 
fore, of a single straight cut, two lunated incisions 
should be made, so as to include an oval piece of 
the integuments. By this means, if the skin be 
adherent, a tedious dissection is avoided ; or, if the 
tumour be very large, the inconvenience of a bag 
of useless integument may be obviated : the haemor- 
rhage, also, will be less ; and the vessels requiring 
ligatures will not be so numerous. The retraction 
of the cord after its division is liable to become a 
source of embarrassment and delay. The retreat 
of this part is usually ascribed to the action of the 
cremaster ; but as the greater part of this muscle, 
together with the organ upon which its action is 
exerted, is cut off at the division of the cord, I 
attribute the retraction chiefly to the elasticity of 
this part, which, after the cord has become relieved 
of the weight of the enlarged testis by which it 
was pulled down, enables it to recover its former 
position. The surgeon should take care to divide 
the muscular and fascious envelope of the cord be- 
fore cutting it across ; as, if this be neglected, some 
difficulty is likely to be experienced in tying the 
vessels after its division. In cases in which the 
cord has retracted within the abdominal ring, the 
surgeon has been obliged to divide the tendon of 
the external oblique muscle, in order to get at the 
bleeding vessels. In a case which came under the 
observation of Sir A. Cooper, the bleeding from the 
vessels of the retracted cord was so profuse, that 
the operator was convinced he had wounded the 

58 



458 CASTRATION. 

iliac artery, and unfortunately proceeded to place 
a ligature on that vessel. The patient died the 
day after the separation of the ligature. The iliac 
artery, though not wounded, had been tied securely 
enough ; but the vessels of the cord, the source of 
the haemorrhage, had been neglected. Mr. Ben- 
jamin Bell mentions two instances of patients 
having lost their lives from hcemorrhage, in conse- 
quence of retraction of the cord before the vessels 
were properly secured."^ This ought never to 
happen ; for the bleeding arteries may always be 
reached by laying open the inguinal canal. But 
this proceeding increases the dangers of the ope- 
ration, in consequence of the proximity of the 
peritoneum. Professor Fergusson mentions a case 
in which the operator had to pursue the vessels 
into the canal : inflammation within the abdomen 
ensued, and carried the patient off within three 
days.t When the vessels of the cord are not pro- 
perly secured, and afterwards bleed, the cellular 
membrane becomes so infiltrated with blood that 
the surgeon not only experiences great difficulty 
in finding the bleeding vessel, but the disturbance 
occasioned by the effusion is liable to induce in- 
flammation and suppuration ; and abscesses from 
this cause have been known to extend to the iliac 
fossa. It was formerly the practice to arrest the 
bleeding from the cord by tightly tying all the 
parts composing it in a single ligature. This un- 



"^ Treatise on the Hydrocele, &c. p. 265. 
t Practical Siiro-ery. p. 54(1 



CASTRATION. 459 

scientific proceeding occasioned severe pain and 
suffering ; produced inflammation ; and in many 
cases was the cause of tetanus. It is needless in 
the present day to offer any caution against a prac- 
tice so rude and unskilful, which has been long 
abandoned by British surgeons. 

There is perhaps no operation more frequently 
succeeded by secondary haemorrhage than castration. 
In morbid enlargements of the testis, the scrotal 
vessels as well as the spermatic undergo consider- 
able increase in size, and pour out blood freely when 
divided. Mr. Sharp castrated a man whose testicle 
weighed above three pounds, where some of the 
vessels were so exceedingly varicose and dilated as 
nearly to equal the size of the humeral artery.^ 
I have myself found the spermatic artery of a testis, 
which was removed in consequence of its being 
affected with malignant disease, as large certainly 
as the radial artery at the wrist. From exposure 
to the cold atmosphere and the corrugation of the 
skin, or in consequence of the patient becoming 
faint, the bleeding from many of the vessels of the 
scrotum often stops in the course of the operation ; 
but as soon as the patient becomes warm in bed, and 
the scrotum relaxes and the circulation is restored, 
the vessels again begin to pour out blood. On this 
account many surgeons prefer waiting an hour or 
two after the patient has been put to bed before 
closing the wound, in order to ensure him from so 
unpleasant and painful an occurrence as the dis- 

* Treatise on the Operations of Surgery, p. 52. 



460 CASTRATION. 

turbance of the dressings and re-opening the wound 
to arrest a secondary hcemorrhage ; and this pre- 
caution I should always recommend, whenever 
vessels particularly large and numerous appear to 
cease bleeding from the effects of syncope or cold. 
Gentle pressure on the scrotum by a dossil of lint 
applied over the wound, and retained by strips of 
plaister or a bandage, and keeping the parts cool by 
an evaporating lotion, are usually, however, sufficient 
to prevent a return of haemorrhage. There is cer- 
tainly less bleeding from the vessels of the scrotum 
when the cellular connexions of the testis have 
been lacerated, than after they have been divided 
by the knife. In one case in which I operated in 
this way, although the testis was of considerable 
size, not a single scrotal vessel required ligature, 
and there was no after-haemorrhage. This practice 
may be adopted with advantage in other operations ; 
as in the removal of a diseased gland from the loose 
cellular tissue of the axilla, and in amputations of 
the mamma. The surgeon may thus save time and 
trouble, and procure a readier cure of the wound, 
fewer ligatures being present to interfere with the 
healing process. 

The disease of the testis requiring castration may 
be complicated with scrotal hernia. In such a case 
the parts must be returned, if possible, into the 
cavity of the abdomen, and protrusion prevented 
during the operation by the fingers of an assistant ; 
and the surgeon should carefully endeavour to dis- 
sect away the cord without wounding the hernial sac. 

In one case of extirpation of the testis, Sir E. 



CASTRATION. 461 

Home relates, " After the operation was com- 
pleted, and the wound dressed, the patient being 
seized with a fit of coughing, to the astonishment 
and dismay of the surgeon, the dressings were 
forced off by a protrusion of several convolutions 
of small intestines : from this it was proved that 
the patient had had a hernia : but the diseased 
enlargement of the testicle had acted as a truss, and 
prevented the rupture from coming down."* If 
the diseased gland be of great size, the practitioner 
will do well to satisfy himself respecting the exist- 
ence of hernia before commencing this operation, 
as it is liable to be overlooked. Dr. Wedemeyer of 
Hanover removed the left testis of a patient who 
had also, on the same side, a reducible scrotal 
rupture of considerable magnitude. The rupture, 
which was reduced at the time of the operation, did 
not subsequently protrude. Considerable inflam- 
mation supervened after the operation ; and it is 
presumed that the descent of the intestine was pre- 
vented by adhesions formed during its process in 
the track through which the rupture had originally 
passed.t 

A few instances are on record in which a testis 
retained in the inguinal canal has become so dis- 
eased as to lead to the necessity of castration. Mr. 
Pott mentions a case of diseased testicle in the 
groin successfully removed by operation at St. 



* Observations on Cancer, p. 236. 

f Journal fur Chirurgie, band. ix. stuck 1 ; as quoted in London 
Med. and Phys. Journal, vol. Ivi. p. 482. 



462 CASTRATION. 

George's Hospital.^ In 1823, Manzoni of Florence 
extirpated a cancerous testis retained within the 
abdominal ring. A similar operation was shortly 
afterwards performed at Pisa for the removal of an 
enormously enlarged cancerous testis, and the canal 
was laid open even into the abdomen. The patient 
recovered from the operation ; the disease, however, 
returned in the glands of the mesentery, and he 
died two years afterwards from the relapse.t Pro- 
fessor Naegele extirpated an enlarged and diseased 
testis from the left groin of a man twenty years of 
age. The peritoneum was wounded, and a portion 
of epiploon protruded. The man survived the ope- 
ration ; but the disease, which is said to have been 
carcinomatous, returned a month afterwards at the 
cicatrix of the wound. :j: 

There would be no great difficulty in extirpating 
a testis seated in the inguinal canal. The first 
incision should be made in the same direction, but 
a little higher up, as in operating for inguinal 
hernia ; and the tendon forming the anterior boun- 
dary of the canal might be divided upon a director 
introduced at the ring, so as fully to expose the 
diseased gland. The danger would certainly be 
greater than after the extirpation of a testis from 
the scrotum, owing to the liability of wounding the 
peritoneum, opening a vaginal sac communicating 

* Lib. cit. 4to. edit. p. 356. Case III. 

+ Fragments d'un Voyage Medicale en Italie, par T. J. E. Petrequin ; 
Bulletin Medicale, Beige, Juin, 1837. 

I Quoted from a German Journal in Archiv. Gen. de Medecine, 
t. xiii. p. 423, 1837. 



CASTRATION. 463 

with the abdomen, or interfering with a testis 
adherent to a piece of intestine. The surgeon 
should not, therefore, interfere hastily with a mor- 
bid gland in this position, especially if the case 
be one of malignant affection ; since it would be 
impossible to determine beforehand, with any de- 
gree of accuracy, to what extent the disease had 
reached. 

I have remarked that castration is not, under 
ordinary circumstances, a dangerous operation. I 
have witnessed, during the last seventeen years, 
about a dozen cases of it, and not one of them 
terminated fatally. In a table of operations per- 
formed at the Hotel Dieu,"* it appears there were 
five deaths in twenty-nine cases of castration, being 
in the ratio of 1 in 4^, which 1 feel satisfied is 
a much higher rate of mortality than would be 
afforded by the results of British practice. 

C. T. Maunoir, in 1820, suggested a new opera- 
tion for the cure of sarcocele, without recourse to- 
the extirpation of the testis.t It consists in cutting 
down upon and tying the spermatic artery, and 
thus interrupting the supply of blood to the organ. 
Two cases in which this plan was adopted are 
detailed. In the first the nerves were tied, as well 
as the artery, and the operation was followed by 
abscesses in the course of the cord. From this 



* Gazette Med. de Paris, Dec. 17, 1842. It should be observed 
that at the Hotel Dieu the mortality from operations is well known 
to be very great. 

f Nouvelle Methode de traiter le Sarcocele sans avoir Recours a 
3'Extirpation dn Testicule. 



464 CASTRATION. 

cause the cure proved tedious; but the testis 
underwent absorption, until scarcely any vestige 
remained. In the second case the artery only v^^as 
tied, and the operation v^as followed by wasting of 
the enlarged gland, and the absorption of the fluid 
collected in the tunica vaginalis. That the tying 
of the main artery should cause the reduction of a 
gland swollen from a chronic inflammation (as was 
probably the case in the above instances), and 
receiving so little blood from other sources, is not 
surprising. There are, however, very few forms of 
morbid enlargement to which this operation is ap- 
plicable. In intractable diseases of the gland with 
an open sore, castration would be preferable ; as 
cutting ofl* the supply of blood would not assist in 
healing the v^ounds, and in malignant aflfections 
such an operation would be quite out of the ques- 
tion. One great objection to its adoption is the 
degree of doubt v\^hich often exists, in cases of 
morbid enlargement requiring operation, respect- 
ing the true character of the disease. 



PART III. 

DISEASES OF THE SPERMATIC CORD. 
CHAPTER I. 

VARICOCELE. 

The term varicocele is sometimes applied to de- 
signate a varicose enlargement of the veins of the 
scrotum, whilst the term circocele is used to denote 
a varicose state of the veins of the cord and testis ; 
but as the scrotal veins are not subject to any 
degree of enlargement that merits the name of 
disease, I shall, as is generally done, apply the term 
varicocele to a morbid dilatation of the spermatic 
veins. 

On dissecting the spermatic veins when varicose, 
they are found dilated, elongated, and more tortuous 
than natural, and apparently more numerous, owing 
to the enlargement of the smaller vessels. In an 
advanced stage of the disease, their coats are 
thickened ; so that when divided the vessels remain 
patent, and thus present the appearance of arteries. 
The enlarged veins hang down below the testis, 
and reach upwards into the inguinal canal ; and 
when very voluminous conceal the gland, encroach 
on the septum, and extend to the other side of the 
scrotum. In a good specimen of these dilated 

59 



466 



VARICOCELE. 



reins which I recently examined, the vessels were 
arranged in three clusters (see 
figure). One formed of the 
larger vessels proceeded from 
the inferior extremity of the 
testis ; the second, in which 
the vessels were less in size, 
but more numerous and tor- 
tuous, arose from the upper 
extremity of the testis ; whilst 
the third and smallest cluster 
surrounded and accompanied 
the vas deferens (1). The dila- 
tation is not confined to the 
veins exterior to the gland : 
even those in the organ itself 
are found varicose, and en- 
larged veins may often be dis- 
tinctly seen ramifying between 
the tunica vaginalis and tunica 
albuginea. The veins occa- 
sionally contain phlebolites, which are lodged in 
round dilatations of the vessels. 

The veins of the left testis are more subject to 
varicocele than those of the right. In upwards of 
120 operations performed by Breschet, in only one 
instance was the varicocele on the right side."* Pott 
met with this disease on both sides of the body in 
only one instance, which is recorded in his treatise 
on Hydrocele.t The disease, however, is far from 




* Landouzy, Du Varicocele, p. 24. 



t Case XXXVIII. 



VARICOCELE. 467 

being so rare on the right side as is generally 
supposed, and often exists on both at the same 
time, although the varicose state of the right 
spermatic veins is always much less than that of 
the left. Landouzy, who has written a work on 
this affection containing much accurate inform- 
ation, states that in eight cases out of seventeen he 
found the veins of the right testis more dilated 
than natural, though they were much less in size 
than those of the left. This writer endeavoured to 
ascertain whether any relation subsists between 
varicocele and varices in other parts. In fifteen 
individuals affected with varicocele whom he ex- 
amined, only one had varicose veins of the lower 
extremities ; and in twenty persons with varicose 
veins of the leg, not one had a varicocele, and no 
connexion could be traced between varicocele and 
haemorrhoids. I have several times examined the 
veins of the lower extremities in persons affected 
with varicocele, but I have only once observed 
varicocele of the left side in connexion with a 
varicose state of the veins of the left leg. 

Of the causes of varicocele, some operate on both 
sides, others only on one. The most influential of the 
former is the hydrostatic pressure consequent upon 
the depending position of these veins, which have 
to support the weight of a column of blood extend- 
ing from the testis to the second dorsal vertebra. 
Many of the Continental writers mention the ab- 
sence of valves as a circumstance conducing to this 
disease : but this is an error, for the larger spermatic 
veins are always furnished with valves, though 



468 VARICOCELE. 

the dilatation which takes place in varicocele pre- 
vents them performing their office. There are seve- 
ral anatomical circumstances which, taken together, 
are sufficient to explain the frequency of varicocele 
on the left side. On the right side the spermatic 
vein joins the vena cava, nearly parallel to the axis 
of that vessel, so that the blood enters in the course 
of the circulation ; but on the left side the sper- 
matic vein terminates in the emulgent vein at a 
right angle, and in a direction perpendicular to the 
venous current from the kidney, which is less 
favourable to the return of blood from the testis, 
since the two currents pursue a different direction. 
The left testis hangs lower than the right ; conse- 
quently the veins must be longer, and the pressure 
produced by the column of blood greater on the left 
side than on the other. The accumulation of the 
faeces in the sigmoid flexure of the colon previous 
to an evacuation tends to produce pressure on the 
spermatic vein, and impede the return of blood 
from the left testis, especially in persons whose 
bowels are habitually constipated. Some persons 
subject to varicocele suffer from it only when the 
bowels are in this condition. But even the natural 
daily accumulation may be sufficient to produce 
some obstruction to the return of the blood by these 
veins. To this cause, I imagine, we must chiefly 
attribute the circumstance that a varicose dilata- || 
tion of the veins of the ovary in the female is nearly 
always confined to the left side. I have had many , . 
opportunities of making this observation ; and Sir 'j 
A. Cooper remarks that he has never met with a 



VARICOCELE. 469 

varicose state of the veins of the right ovary, which 
cannot be attributed to any variation in the height 
of the column of blood, since the two ovaria are on 
the same level. 

The occasional causes of varicocele not depending 
on organization include all those circumstances 
which tend either to determine the blood in an 
inordinate degree to the testes, or to impede its 
return to the heart, and which operate chiefly by 
weakening the coats of the vessels. In the first 
class are abuse of venery, masturbation, and at- 
tacks of orchitis. The second class comprehends 
tumours developed in the abdomen, enlargement 
of the lumbar glands, hernial swellings which press 
on the cord, trusses improperly adjusted, an accu- 
mulation of fat in the omentum and mesentery, 
and belts worn round the abdomen. Certain kinds 
of exercise greatly prolonged, as riding and rowing, 
and sudden and violent efforts, as in straining, also 
give rise to varicocele. That the latter powerfully 
conduces to the production of a dilatation of the 
spermatic vessels, may certainly be concluded from 
the circumstance that the stress to which they are 
subjected during violent exertion is sometimes so 
great as to occasion rupture of their coats and 
extravasation of blood, as was pointed out in treat- 
ing of haematocele of the spermatic cord. Pa- 
tients, too, often ascribe the origin of the disease 
to some sudden effort or straining. Want of the 
proper support afforded to the testes and spermatic 
vessels by the contractility of the scrotum likewise 
predisposes to this disease. It is partly on this 



470 VARICOCELE. 

account that varicocele is more common in warm 
than in cold climates, and in persons of a weakened 
and relaxed habit than those of a robust and vigorous 
constitution, and is more troublesome in warm than 
in cold weather. 

In the slight degree and chronic state in which 
we more frequently meet with this disease, the 
dilatation of the spermatic veins produces no in- 
jurious effects on the gland ; but when highly or 
rapidly developed, a varicocele interferes so much 
with the circulation of the testis as to occasion a 
diminution in its size. This effect of varicocele 
upon the nutritive condition of the testis was 
originally noticed by Celsus.^ Sharp observed, in 
a case of this disease, a gradual wasting of the body 
of the testicle, which at length was diminished to 
the size of a hazel-nut.t A partial atrophy of the 
gland, co-existing with varicocele, has come under 
my observation in more than a dozen instances ; 
indeed, in nearly all cases in which there was a 
decided dilatation of the spermatic veins on one 
side only, the testis of that side was the smaller 
of the two. In one instance I found the gland 
diminished to half the size of the one on the sound 
side ; and in a man aged fifty-six who was found 
drowned, and had a varicocele on the left side, the 
testis was so reduced that it scarcely exceeded the 
usual size of the organ in an infant. Some years ago a 
tall, seafaring man, about forty-five years of age, 
was under my care at the London Hospital on ac- 

* Lib. vii. chap. 18. | Critical Inquiry, p, 100, 



VARICOCELE. 47 1 

count of a varicose ulcer on the left leg, who had a 
large varicocele on the left side, and a testis on 
the same side so wasted, that it could scarcely be 
felt even through the tunica vaginalis, which was 
loosely distended with fluid. 

In forty-five cases in which Landouzy noted the 
age at which varicocele was first observed, ten 
having been taken from authors, and thirty-five 
having come under his own observation, the age 
was as follows : 



From 9 years to 15 


- 


13 


15 25 


- 


29 


25 35 


- 


3 



45 

This result very nearly agrees with my own 
experience in the cases in which I have had an 
opportunity of ascertaining when the disease first 
commenced. They show that the period of puberty 
is the time at which varicocele most commonly 
occurs. I have only once met v/ith it before that 
age. The patient was a lad aged thirteen, and the 
varicocele was on the left side, and was first ob- 
served a week before, after a fall. The periodic 
enlargement of the testes had not commenced, but 
the left gland was smaller than the right. 

Symptoms. — A varicose distension of the sper- 
matic veins in general takes place so gradually, and 
produces so little inconvenience, that it is seldom 
detected until the affection has made some progress, 
and is then only discovered accidentally. When some- 



472 VAKICOCELE. 



I 



what advanced it occasions a sensation of weight in 
the testis, and a feeling of uneasiness in the course 
of the spermatic cord, which often extends to the 
loins, and is aggravated by exercise, as riding or 
walking. The patient is then apt to carry his hand 
to the scrotum to relieve the sensation of weight, 
or to give the part a more favourable and con- 
venient position in his clothes. On examination 
the scrotum is found to be long, pendulous, and 
lax ; and in persons of a thin and delicate skin has 
a slight livid appearance, the colour of the blood 
in the veins being indistinctly visible through the 
integuments. A pyriform swelling is observed in 
the course of the cord, occasioned by the enlarged 
veins. This when handled has a soft, doughy, in- 
elastic feel, and communicates to the fingers a 
sensation which has been compared to that of a 
bundle of ropes or earthworms. The dilated veins 
may be traced upwards into the inguinal canal in 
advanced cases ; and when very pendulous they 
sometimes form a double cone, the testis being 
nearly in the centre, and the varicose veins above 
and below it. The swelling is diminished by cold 
and the recumbent position ; and on the other hand 
is increased by warmth, the erect position, and by 
straining and coughing. The disease, indeed, is 
often first discovered by the patient whilst taking a 
bath, or during an attack of catarrh. The disten- 
sion of the vessels is also greater towards evening 
than in the morning. Landouzy has noticed a 
curious fact in connexion with this disease ; viz. the 
marked relief experienced by patients during and 



VARICOCELE. 473 

immediately after coition, followed by a severe ex- 
acerbation of the symptoms the next day.^ This 
is owing to the support afforded to the vessels of 
the part by the tone and contraction of the scrotum, 
and the increased vigour of the circulation during 
the venereal orgasm ; but as this is only temporary, 
when relaxation and lassitude ensue the symptoms 
of varicocele return with greater severity than 
before. I can confirm the latter observation ; pa- 
tients having several times complained to me of 
their symptoms being aggravated for several days 
after sexual connexion. 

Varicocele, when slight, often remains stationary 
for a considerable time, neither increasing nor pro- 
ducing inconvenience. This is more particularly 
the case with varicocele in old people, and also on 
the right side ; so that patients who have discovered 
the disease on the left side remain for years in 
ignorance of any thing wrong on the right, which 
they believe to be sound, though it contains the 
rudiments of the same affection as exists on the 
left. In all cases varicocele on the right side is 
less voluminous, occasions less uneasiness, and leads 
to consequences less grave than the same affection 
on the left, and very rarely requires any operation 
or even treatment for its relief 

If a patient affected with slight varicocele avoids 
fatigue and the exciting causes of the disease, and 
wears a suspensory bandage, its progress is usually 
arrested ; but if permitted to increase it becomes 

* Lib. cit. p. 76. 
60 



474 VARICOCELE. 

a source of continual suffering. Slight exertion, 
warmth, or excitement of any kind increases the 
local uneasiness ; so that the patient is prevented 
from taking exercise, and is disabled from earning 
his livelihood by labour. The pain and distress 
occasioned by this disease vary, however, a good 
deal, and are not exactly proportionate to the size 
of the varicocele. In cases of varicocele of large size 
the pain is sometimes very slight ; whilst in others 
small in volume it is occasionally very severe. 
Persons affected with it at an early age, on the 
whole, suffer more than those who are attacked 
when advanced in life. The pain in some cases is 
dull and heavy ; in others it assumes a neuralgic 
character, darting and shooting, supervening sud- 
denly, and occurring in irregular exacerbations. 
The pain is sometimes so excessive and intolerable, 
that patients have gladly submitted to the operation 
of castration for their relief, which has been per- 
formed at the urgent request of the patient by 
Gooch,* Sir B. Brodie,t Mr, Key,J and others. 

Severe neuralgic pains are not, however, to be 
regarded as an essential or common character of 
this disease; and, as before mentioned, they are not 
dependent on the degree of vascular dilatation. A 
combination of a varicose state of veins and neu- 
ralgia or morbid sensibility is occasionally observed 



* Practical Treatise on Wcunds and other Chirurgical Subjects, 
vol. i. p. 244. 

f London Medical and Physical Journal, vol, Ivi. p. 299. 

I Sir A. Cooper's Observations on the Testis, p. 224. Vide Case by 
Mr. Thompson of Stalybridge, Lancef, vol. ii. 1839-40, p. 137. f 



VARICOCELE. 475 

in other parts. Sharp mentions, in his Critical 
Inquiry, a case where the cephalic and median veins 
in the bend of the arm were varicose for near two 
inches, and so extremely painful that the patient 
could find no relief till he cut them away.^ I have 
myself noticed in some cases a degree of neuralgia 
attending varicose veins of the lower extremities ; 
and a few years back I extirpated from the wrist 
of a girl eleven years of age a small plexus of vari- 
cose veins situated at the ulnar side and edge of 
the lesser vola, near the prominence of the pisiform 
bone, the skin covering which was so exquisitely 
tender that she could scarcely bear me to touch 
the part, and was nearly deprived of the use of the 
hand. The operation effectually removed the mor- 
bid sensibility and pain. 

Though varicocele usually occurs as a chronic 
affection, it sometimes forms suddenly and ad- 
vances rapidly, appearing shortly after a severe 
injury or strain, which had probably occasioned a 
dilatation of the coats of the veins from which they 
were unable to recover. There may have been a 
previous tendency to the complaint ; but patients 
often ascribe its origin to some sudden effort, since 
which they had experienced the annoying symp- 
toms of the disease. In these acute cases, which 
nearly always occur in early life, the suffering is 
much greater than in the more chronic cases. Va- 
ricocele has also been known to occur as an acute 
affection shortly after an attack of orchitis. Mr. 

* P. lOL 



476 VARICOCELE. 

Pott has recorded three remarkable cases, in which 
varicocele made its appearance, not only suddenly 
and with acute pain, but was attended with very 
rapid wasting of the testis."^ — 1. A young man after 
a fatiguing journey was seized in bed with a violent 
pain in the back, which (to use his own words) 
shot down into his stone. The pain was so great 
that he sent for immediate assistance, and was bled, 
but without relief There was no tumour of the 
testicle or scrotum. The pain continued without 
remission all the next day, and he was again bled 
and purged. On the third day, toward evening, 
the pain totally left him, and a fulness appeared in 
the groin tending down towards the testicle. This 
made him so uneasy that he got into a post-chaise 
and came home to London. His journey brought 
on a return of the pain ; but by losing more blood, 
keeping in bed, and suspending the parts, he be- 
came easy, and all the tumefaction dispersed except 
a small fulness of the spermatic cord occasioned by 
the varicose state of its vessels. But the testicle 
was so diminished as to be hardly perceptible. — 
2. An ostler was thrown from his horse, and struck 
his groin against the pommel of the saddle. It 
gave him exquisite pain. He was brought imme- 
diately to the hospital. When he was examined, 
there was no apparent swelling of the testicle or 
spermatic cord. He was largely blooded and 
purged • his pain continued two days, and when it 
left him the spermatic vessels became greatly vari- 

* Lib. cit. p. 46a. Cases XXXVL XXXVIL and XXXVIIL 



VARICOCELE. 477 

cose. He left the hospital free from pain, but his 
testicle on that side was scarcely discernible. — 
3. A gentleman aged twenty-five, after being heated 
by exercise went to bathe. In the ensuing night 
he was seized with coldness and shivering, followed 
by heat, thirst, and a slight sweat. He was bled, 
purged, and kept in bed. For three days his fever 
was unremitting ; but on the fourth he became 
cooler, and was seized with a most acute pain in 
the loins, for which he was again bled and purged. 
On the fifth day his back became easy ; but both 
testicles, though very little swollen, were extremely 
tender : in a very few hours the spermatic vessels 
were so distended as to make an apparent tumour. 
By fomentation, poultice, and rest, all uneasiness 
was removed in about a fortnight ; but at the end 
of that time both surgeon and patient were exces- 
sively astonished at not being able to find the tes- 
ticles. The patient came to London immediately 
and consulted Mr. Pott, who found the spermatic 
vessels full and varicose ; the vasa deferentia too 
large, and rather too hard, as also the epididymes ; 
but there was not on either side the least appear- 
ance of a natural testicle : a flattened, compressed 
kind of membranous substance, which he supposed 
was the tunica albuginea, seemed to hang from 
each epididymis ; but there was not any trace or 
vestige of the glandular or vascular parts of either 
testis. 

The concise history which Mr. Pott has given 
of these cases seems to afford grounds for sus- 
pecting that there was some further cause than a 



478 VARICOCELE. 

varicose aiTection of the veins of the testis for the 
acute symptoms by which they were character- 
ized. In all three the complaint was preceded by 
the sudden occurrence of acute pain, without tume- 
faction of the testis, scrotum, or cord ; and when 
the pain subsided, which happened in a few days, 
the swollen vessels then became apparent, and the 
testes rapidly disappeared. In the two first cases 
this took place on one side only ; in the third, in 
which the complaint was preceded by fever, the 
symptoms were more severe than in the two former, 
and both testes wasted away entirely in a fortnight. 
Now such is not the history of varicocele as I have 
met with it, nor does it correspond with the ac- 
counts usually given of the disease. Its progress 
is in general chronic ; and though sometimes acute, 
I have certainly never known it to become deve^ 
loped with such rapidity as in these cases. The 
pain, too, is rather heavy and dull than violent, 
and does not precede, but seems consequent on, the 
varicose enlargement ; and instead of the testes 
decaying rapidly, the atrophy takes place in the 
most slow and gradual manner, being often imper- 
ceptible in varicoceles of many years' duration, and 
rarely going on to the entire destruction of the 
gland. I scarcely know in what way such a rapid 
and total wasting of the testis as appears to have 
taken place in these cases could have been produced, 
unless from some cause cutting off the chief supply 
of blood by the spermatic artery. The same cause 
might likewise obstruct the spermatic veins. In 
the last case, it is observed that the vasa deferentia 



VARICOCELE. 479 

were too large and rather too hard, as also the 
epididymes; which would seem to indicate that 
these parts, if not the testis, had been the seat of 
inflammation. I think, therefore, there is suffi- 
cient reason to question the propriety of consider- 
ing these cases as simple examples of varicocele. 

Diagnosis. — The symptoms of varicocele slightly 
resemble those of a scrotal hernia. Like hernia, 
the tumefaction in varicocele increases when the 
patient is in the erect position ; subsides spon- 
taneously, or on pressure, when he is in the recum- 
bent ; and soon reappears when he again assumes 
the erect posture. When the dilated condition of 
the veins extends into the inguinal canal the ring 
is enlarged, and the swelling increases, and receives 
a slight impulse in coughing. A varicocele, how- 
ever, cannot well be mistaken for an intestinal 
hernia ; but the student may sometimes be unable 
to distinguish the feel of the tortuous and dilated 
vessels from that of an omental protrusion. The 
best mode of making the diagnosis is as follows. 
The patient having placed himself in the recumbent 
position, the testis of the side affected is to be raised 
until the swelling disappears. The surgeon must 
then press gently with the fingers on the external 
abdominal ring, and direct the patient to rise. If 
the case be a varicocele, the swelling soon reappears; 
but if it be a hernia, the descent of the omentum 
is prevented by the pressure. As the tumefaction 
is reproduced, it commences, if a varicocele, from 
below ; if an omental hernia, from above. In 
making this examination, care must be taken that 



480 VARICOCELE. 

the pressure be not too great, or the veins will remain 
empty. A varicocele might possibly be mistaken 
for a congenital hydrocele, which likewise swells in 
the erect position and disappears in the recumbent ; 
the transparency of the tumour in hydrocele is 
sufficient to set all doubt at rest. Though I have 
given the above directions, I must observe that I 
have never met with a case of varicocele in which 
there was any difficulty in detecting the nature of 
the case, or distinguishing the disease from other 
affections of the part. 



PALLIATIVE TREATMENT OF VARICOCELE. 

Varicocele is almost an incurable disease ; but as 
it is an affection which, in the mild form that is 
more commonly met with, produces little suffering 
or even inconvenience, the treatment chiefly re- 
quired is to keep the scrotum and testes well 
supported with a suspensory bandage, in order to 
diminish the length of the vessels, and the w^eight 
of the column of blood circulating in them. As it 
is desirable that the parts should be kept cool, the 
suspender should be made of open silk net. A cold 
evaporating lotion is usually recommended in these 
cases ; and no doubt benefit might be derived from 
its constringent effects, if the parts were kept free 
from the clothes around, so as to permit evapora- 
tion to take place, but this is seldom convenient. 
The lotion used should be free from smell. The 
parts may be freely soused with cold spring water 



VARICOCELE. 48 1 

morning and evening, or the patient may daily use 
the shower bath. The dress ought to be as light 
as comfort will admit of, and not tight about the 
abdomen. Fatiguing exercise, warm baths, much 
indulgence in venery, — every thing, in fact, which 
tends to determine the blood to the testes and 
scrotum must be avoided. The bowels should be 
properly regulated, and any disposition to costive- 
ness obviated by gentle aperients, or, what is better, 
by enemata of warm water thrown well up into the 
colon every morning, in order to remove the feculent 
collections from this part of the intestine. By 
these means, if we cannot correct the dilated con- 
dition of the veins, we may generally prevent its 
increasing, and contribute to the comfort and 
health of the patient. 

For the purpose of supporting the testis in cases 
of varicocele, Mr. Wormald of St. Bartholomew's 
Hospital makes use of the following plan.^ — The 
lower part of the scrotum, whilst the patient is in 
the recumbent position and the veins comparatively 
empty, is drawn through a ring about an inch in 
diameter, made of soft silver wire of a suitable 
thickness, padded, and covered with wash-leather. 
The sides of the instrument are then pressed to- 
wards each other with sufficient force to prevent 
the scrotum escaping. Mr. Wormald represents 
that great relief has been experienced in cases of 
varicocele from this simple contrivance. I have 
tried this plan, but have not found that it possesses 

* Medical Gazette, vol. xxii. p, 194. 
61 



482 VARICOCELE. 

any particular advantage over the suspensory truss : 
it is equally annoying to the patient's feelings, and 
cannot always be steadily fixed, so as to answer the 
purpose intended. 

As the above means are only palliative, and in 
severe cases do not always afford sufficient relief, 
and as patients, especially at the age at which va- 
ricocele usually occurs, do not much like being 
condemned to wear a bandage for the remainder of 
their lives, further assistance is often required from 
the surgeon. 



RADICAL TREATMENT OF VARICOCELE. 

In order to afford a permanent and morel 
complete support to the testis, and to render a 
suspensory bandage unnecessary, Sir. A. Cooper 
suggested a very simple operation ; viz. the re- 
moval of a portion of the relaxed scrotum, leaving 
the remaining part to form adhesions and to con- 
stitute a natural suspensory bandage. He states 
that the operation is safe, effectual, and by no 
means painful ; and he directs its performance in 
the following manner. — " The patient being placed 
in the recumbent posture the relaxed scrotum is 
drawn between the fingers ; the testis is to be 
raised to the external ring by an assistant ; and 
then the portion of the scrotum is removed by the 
knife or knife-scissors : but I prefer the former. Any 
artery of the scrotum which bleeds is to be tied ; 
and a suture is then made to bring; the ed^es of the 



VARICOCELE. 483 

diminished scrotum together. The patient should 
be kept for a few hours in the recumbent posture, to 
prevent any tendency to bleeding ; and then a sus- 
pensory bag is to be applied to press the testis up- 
wards, and to glue the scrotum to the surface. The 
only difficulty in the operation of removing the scro- 
tum by excision is in ascertaining the proper quan- 
tity to be removed ; but it adds but little to the pain 
if a second portion be taken away, if the first does 
not make sufficient pressure on the spermatic cord. 
It is of no use to remove a small portion of the 
scrotum, for from doing this I have failed. When 
the wound has healed the varicocele is lessened, 
but not always entirely removed ; but the pain and 
distressing sensations cease, if sufficient of the 
scrotum be removed."^ Sir A. Cooper recommended 
this operation only in those cases of varicocele in 
which the patient suffers great local pain ; in cases 
in which he is most urgent to have the swelling 
and deformity of the part removed ; and more espe- 
cially in those instances in which the function of 
digestion suffers, and there is a great degree of 
nervousness and of mental depression. For slighter 
cases a suspensory bandage must still be recom- 
mended.t In the paper from which I have quoted, 
five cases are related in which the painful symptoms 
of varicocele were fully relieved by this operation : 
four of them were operated on by Sir Astley him- 
self, and the fifth by Mr. Key. The son of a medi- 
cal gentleman of my acquaintance, when sixteen 

+ Guy's Hospital Reports, vol. iii. p, 9. f Ibid. p. 13. 



484 VARICOCELE. 

years of age, had part of his scrotum excised by 
Sir A. Cooper in May, 1840, in consequence of 
varicocele. The effects of the operation were mild ; 
very little confinement was necessary, and the parts 
healed in little more than a week. In December, 
1842, he had continued relieved from all uneasiness ; 
and the testis was of proper size, though the veins 
still remained enlarged. In a case operated on by 
Dr. Watson of New York, the patient was perma- 
nently relieved of the dragging sensation and pains 
of which he complained before the operation.* 
Mr. Bransby Cooper has recordedt another case of 
severe varicocele, in which the operation was at- 
tended with a very beneficial result ; but the effects 
described were extremely severe, — indeed fully as 
much so as after operations performed on the veins, 
and not altogether devoid of danger: the cure also 
proved very tedious. A short time since I exa- 
mined a man, part of whose scrotum had been 
excised by Sir A. Cooper on account of varicocele, 
but who derived so little benefit from the operation 
that he afterwards subm.itted to castration ; and a 
medical friend lately informed me that in one of the 
published cases of success the disease subsequently 
returned as bad as ever. Mr. Luke made trial of 
the operation in the following case at the London 
Hospital. — W. Dudley, an engineer aged twenty-one, 
was admitted into the London Hospital in May 1841, 
with a varicocele on the left side. He stated that 



* New York Med. and Surg. Journal, Oct 1840. 
f Guy's Hospital Reports, vol. iv. p. 201. 



VARICOCELE. 485 

it came rather suddenly after he had exerted him- 
self in lifting a plank of wood. The veins were 
greatly enlarged, and formed a plexus which de- 
scended below the testis ; the scrotum was lax and 
pendulous, and the left testis was smaller than the 
right. The affection was attended with a heavy 
aching pain in the testis and groin, and uneasiness 
in the loins, which were so much increased by any 
exertion that he was obliged to abstain from hard 
work. The symptoms were only partially relieved 
by a suspensory bandage and cooling lotion ; and as 
he was anxious to obtain permanent relief, he was 
admitted into the hospital for the purpose of having 
part of the scrotum excised. A considerable por- 
tion of the integuments was removed with the 
knife, so as to expose both testes. The edges of 
the wound were brought together with three liga- 
tures, and closed with strapping ; but the testes were 
with difficulty prevented from protruding at the 
intervals of the sutures, especially the right, the 
tunica vaginalis of which contained a small quantity 
of fluid. There was very little bleeding, and only 
two vessels required ligature. The wound healed 
up very slowly, and was not entirely closed till six 
weeks after the operation, during the greater part 
of which time he was kiept in bed. The testes were 
then found to be well braced up and supported, 
and the man was a good deal, but not wholly re- 
lieved, of the uneasiness in the groin and cord he 
had previously experienced. He complained for 
some time afterwards of pain in the loins ; but as 
he regained his health and strength this left him, 



486 VARICOCELE. 

and he resumed his work. I have not since been 
able to obtain any further account of the case. 

This operation has not been generally adopted 
by operating surgeons, and considerable doubt is 
entertained of its efficacy. I have taken some 
pains to ascertain the amount of benefit which it is 
capable of affording ; and from the inquiries that I 
have been able to make it appears to me that ex- 
cision of a portion of the scrotum is calculated to 
arrest the progress of varicocele, and afford full and 
permanent relief, only in those cases in which the 
painful symptoms of the disease admit of being 
temporarily but completely removed by suspending 
the parts in the hand, or in a well-adjusted sus- 
pensory bandage ; when the contraction of the 
scrotum succeeds in compensating for the previous 
laxity of the tissues, gives adequate support to the 
dilated veins, and sufficiently diminishes the pres- 
sure of the column of blood circulating in them. 

The objects contemplated in the preceding ope- 
ration, viz. shortening of the scrotum and per- 
manent support to the testis, have been attempted 
to be obtained in another way by Dr. Lehmann, a 
German surgeon. The mode of operating is very 
similar to that which he states he has in several 
cases adopted successfully for the radical cure of 
hernia. A portion of the relaxed scrotum is pushed 
up on the fore finger, and invaginated into the part 
above it, till the finger reaches the abdominal ring. 
A broad curved needle, with a double thread passed 
through an eye near its point, is then carried 
through the bottom of the inverted portion of the 



VARICOCELE. 487 

scrotum, and made to penetrate the integuments 
immediately over the external ring. The thread is 
next removed from the eye, and the needle drawn 
back, and again carried through the scrotum and 
integuments at the distance of about half an inch 
from the parts previously penetrated. The threads 
passed through the two apertures being drawn, the 
invaginated portion of scrotum is pulled up to the 
desired height. The threads are then tied in a 
knot, and the parts are left for eight or nine days, 
by which time adhesion takes place between the 
opposed surfaces of the inverted portion of the 
scrotum and that into which it is pushed. The 
author relates six cases in which this mode of 
operating was adopted with success, but in none of 
them had sufficient time elapsed to enable him to 
determine that the treatment was permanently 
beneficial.^ This plan does not appear to possess 
any advantages over the operation of excision of 
part of the scrotum ; and I should think it must be 
liable to even a greater risk of failing in its object 
than the latter operation. 

Various attempts have been made to obtain a 
radical cure of varicocele by causing obliteration 
of the dilated veins. This has been eifected in 
four different ways. 1. By division of the vessels ; 
2. By ligature ; S. By compression : and 4. By ex- 
cision. 

1. Division of the Vessels, — This operation was 
first practised by Sir B. Brodie. A man twenty- 

* Med. Zeitung-, Dec. 2, 1840 ; as quoted in Brit, and For. Med. 
Rev. No. xxii. April 1841, p. 529. 



488 VARICOCELE. 

one years of age was admitted into St. George's 
Hospital with a varicocele on the left side, prin- 
cipally situated at the posterior part of the epi- 
didymis, which, though not very large, caused a 
very considerable degree of pain, especially in the 
evening, when the veins were more distended than 
in the morning. Finding that the pain was re- 
ferred almost wholly to the cluster of varicose 
veins situated at the posterior part of the epididy- 
mis, he was induced to believe that the sufferings 
of the patient arose from the pressure of the tumour 
on some contiguous nerve or nerves, and that if the 
dilated veins forming it could be obliterated the 
pain would be relieved. With this impression on 
his mind, Sir B. Brodie performed the following 
operation. He divided, with a sharp-pointed bis- 
toury, the skin and cellular texture at the posterior 
part of the scrotum, so as to expose the varicose 
cluster ; and then, by a second incision, he divided 
the varicose cluster itself, cutting through its 
centre. When first exposed the cluster was of 
^bout the size of a horse-bean, of a purple colour: 
on being divided it immediately collapsed, and 
there was a slight venous haemorrhage. Some cold 
lotion was applied, the wound being allowed to re- 
main open, in order to favour the escape of blood, 
and prevent its effusion into the cellular texture of 
the scrotum. Some inflammation and tumefaction 
of the scrotum followed the operation ; but there 
was no fever, nor much uneasiness of any kind- 
A month after the operation the wound was healed, 
and the patient was free from pain. A slight 



I 



VARICOCELE. 489 

degree of hardness remained where the divided 
cluster of veins was situated. I have not heard 
that this operation has been adopted in other cases 
of the disease. 

2. Ligature. — Celsus recommended cutting down 
upon the spermatic veins, and the application of 
a ligature around them ; an operation which has 
been frequently performed since his day by many 
of the older surgeons. This operation is adequate 
to the cure of the disease ; but is not free from 
danger, owing to its liability to induce phlebitis. 
Sir Everard Home cut down upon and tied the 
spermatic veins for the cure of varicocele in a pa- 
tient in St. George's Hospital. In this case, accord- 
ing to Sir B. Brodie, venous inflammation took 
place, attended with so much constitutional dis- 
turbance that the patient nearly died.^ It is 
open also to the further objection of occasioning 
atrophy of the testis. Delpech, a surgeon of dis- 
tinction in France, was assassinated by a man whom 
he had cured of double varicocele a year before by 
tying the dilated veins. The patient's testes were 
found after death wasted and soft. 

To avoid the risks consequent upon the simple 
application of a ligature, many modern surgeons 
have had recourse to a plan for the obliteration of 
the dilated veins which was first tried by M. Davat 
on the veins of animals.t This plan consists in 



* Lond. Med. Gaz, vol. xiii. p. 379. I have been informed that 
several of the patients whose spermatic veins had been tied by Roux 
in Paris, for the cure of varicocele, died from the operation. 

t Vide Archives Gcnerales de Medecine, 11 ser. t. xi. p. 1. 1833. 



490 VARICOCELE. 

passing a straight pin or needle through the 
scrotum, and underneath the varicose vessels, be- 
tween the latter and the yas deferens, and then 
twisting a strong silk ligature around the project- 
ing extremities of the pin in the form of the figure 
8, with sufficient tightness to compress and flatten 
the vessels and arrest the circulation through them. 
Inflammation is by this means excited in the coats 
of the vessels ; and the sides of the inner one being 
retained in contact, the vessels soon become ob- 
literated by adhesion. The pin after remaining 
in a few days is removed, and the sores produced 
by it soon heal up. Velpeau and Jobert"* have 
practised this operation with success in several 
cases, and it has also been performed in America,! 
and in this country by Mr. Liston± and other sur- 
geons, with favourable results. The pins should 
not remain in longer than four or ^ve days, or 
they are liable to occasion ulceration of the veins, 
and suppuration in the cellular tissue of the scro- 
tum. In large varicoceles it is necessary to intro- 
duce a second or third pin at the distance of from 
half an inch to an inch from each other. 

M. Ricord of Paris also has recourse to the liga- 
ture, which he applies in the following ingenious 
manner : — The vas deferens is separated from the 
mass of veins ; and the latter being taken up with a jj 
fold of the scrotum, a flat lance-shaped needle, armed 
with a double-looped thread, is passed beneath them. 

* Bulletin Generale de Therapeutique, Aout, 1837. 

t American Journal of the Medical Sciences, vol. xxiii. p. -SOO. 

I Practical Surgery^ 3d edit. p. 446. 



■ VARICOCELE. 491 

When the needle has been passed completely 
through the skin from one side to the other, the 
veins are let go, the skin alone being now held up ; 
and then a second needle, similarly armed, is passed 
through over the veins, entering at the same hole 
by which the first needle was thrust out, and pass- 
ing out at the same hole by which it entered. The 
bundle of veins is thus fixed between two double 
threads, of which one passes over the other beneath 
it. The ends of each double thread on each side 
are then passed into the loop of the other, and now 
by drawing these ends in opposite directions the 
vessels are tied beneath the skin. By this kind 
of ligature the vessels may either be suddenly 
constricted, or be tied gradually, in a manner some- 
thing like that practised by Breschet ; or most con- 
veniently by a properly adapted serre-nceud, after 
the fashion of a tourniquet. It is usually from 
the tenth to the twentieth day that the vessels are 
divided by this means ; and their division may be 
easily recognised by the freedom with which the 
ligatures may be drawn from one side to the other 
without being, as they were before, retained by 
the parts which they inclosed. Sometimes a slight 
oedema of the scrotum supervenes after the opera- 
tion, and Ricord has twice observed rather a con- 
siderable serous efiusion in the tunica vaginalis. 
In one patient also, who a few days afterwards 
exposed himself to great fatigue, a slight abscess 
formed in the cellular tissue ; but with these ex- 
ceptions there has been no important accident. If 
the patient is strong and plethoric, he is to be bled 



492 



VARICOCELE. 




from the arm directly after the operation ; the 
horizontal position must be maintained till the 
vessels are cut through, and the bowels must be 
carefully kept open. Twelve pa- 
tients had been operated on in 
this manner at the Venereal Hos- 
pital, and in all the most com- 
plete and satisfactory result had 
been obtained."* 

Mr. Luke has lately cured a 
case of varicocele at the London 
Hospital with the ligature, ap- 
plied by means of an instrument 
termed a " fistula tourniquet," 
with which he has successfully 
treated several cases of fistula in 
ano. — Matthew Quin, a tall and 
muscular Irishman, aged twenty- 
four, was admitted in August, 
1842, on account of varicocele 
on the left side. The left testis was about half the 
size of the right, and above it there was a consider- 
able swelling formed by the varicose spermatic veins. 



* British and Foreig-n Medical Review, July, 1840, p. 270. (From 
Bulletin Generale Therapeutique, Mars, 1840.) Several other modi- 
fications of the operation by ligature have been practised by different 
French surgeons ; but they are not important. 



(iV) Mr. Luke's tourniquet for the cure of fistula and varicocele. 

A. The screw. 

B. Button upon which the screw turns. 

C. Movable nut, 

D. Key for turning the screw in order to tighten the ligature. 



VARICOCELE. 49o 

He experienced a dragging pain in the course of the 
cord, and an uneasy sensation of weight, which were 
only partially relieved by supporting the parts. He 
had been a private in the Light Dragoons, and he 
attributed the origin of his complaint to his testis 
having been accidentally struck against the saddle in 
riding about fourteen months before. He had left 
the regiment invalided in consequence of it about 
two months. — September 3. Mr. Luke, the patient 
standing before him, having separated as far as 
possible the whole of the plexus of varicose veins 
from the vas deferens, passed a straight sewing 
needle armed with a ligature of strong dentist's silk 
through the root of the scrotum between these 
parts ; and having attached the ends of the ligature 
to the fistula tourniquet, secured them so as to 
make gentle pressure on the veins. The man was 
then sent to bed. Three days afterwards the liga- 
ture was tightened by turning the screw, and a 
grain of calomel was directed to be taken at night. 
As the ligature cut through the included parts and 
got slack it was again tightened, the turning of the 
screw being stopped immediately the patient com- 
plained of pain. He had continued so free from 
pain during the treatment that at the end of ten 
days the calomel was omitted, and he was allowed 
to walk about the ward and take his diet as usual. 
The ligature came away on the 28th, and on the 
30th the wound was healed. A few dilated veins 
were still felt in the lower part of the scrotum. 
The man was greatly relieved, though he was not 
quite free from the sensation of weight without 



4 94 VARICOCELE. 

wearing the suspensory bandage. The testis was 
not diminished in size. — Oct. 4. He was discharged 
from the hospital. — Dec. 20. He was still quite 
well, and had taken a situation as policeman. The 
testis was about the same size as before the opera- 
tion, and the tumefaction of the veins removed. 

3. Compression, — In the preceding operations the 
veins are pressed upon by the pin or ligature with 
which they are immediately in contact, and are 
thereby liable to become inflamed. To obviate 
this disadvantage M. Breschet has contrived a pair of 
forceps, to cause obliteration of the veins, by making 
firm pressure on them from outside the scrotum. 
By means of this instrument, the blades of which 
are well padded, and admit of being closed by 
screws, the walls of the dilated veins are at once 
brought into contact ; blood coagulates in the vessels ; 
and adhesion taking place, the danger to which the 
other plans are liable is said to be avoided, and by 
securing the spermatic artery from compression 
atrophy of the testis is also prevented. In thirteen 
cases in which this operation was performed there 
was only one relapse, which was owing to a vein 
not being included in the forceps.^ A writer who 
witnessed the treatment of several of Breschet's 
cases, and has reported favourably of the operation, 
has nevertheless represented the inflammation and 
swelling consequent upon it as being considerable, 
and the cure as proving tedious.t 

* Landouzy, lib. cit. 

f Vide Observations on M. Breschet's Operation for the Radical 
Cure of Varicocele, by W. H. Walshe ; Medical Gazette, vol. xv. p. 369. 



VARICOCELE. 495 

Under the head of Compression must be men- 
tioned a mode of relieving varicocele, which, as far 
as may be judged from the few cases in which it 
has hitherto been tried, bids fair to become a valu- 
able acquisition to our means of treating this obsti- 
nate disease. The history of the plan is as follows. 
A surgeon suffering from a varix in the leg, having 
heard the late Sir Charles Bell state, in his lectures 
at the College of Surgeons, in illustration of the 
fact of the dilatation of a varicose vein being caused 
solely by the pressure of the column of blood, that 
if the distended vein be compressed with the finger 
the swollen condition of the vessel beneath shortly 
disappears, was led to apply the principle thus in- 
dicated to the treatment of his own case, which was 
attended with a satisfactory result. This gentle- 
man mentioned the circumstance to Mr. Aston Key, 
who was accordingly induced to adopt the same 
principle in the treatment of cases of varicocele ; 
and in a private communication with which I have 
been kindly favoured by Mr. Key, he has assured me 
that he believes the practice resorted to is effective, 
and applicable to the majority of cases of varicocele. 

In a patient affected with this disease, if the 
spermatic cord be pretty firmly compressed between 
the fingers while the patient is in the recumbent 
position and the vessels are empty, it will be found, 
on his assuming the erect posture, that the vessels, 
instead of swelling as before, still remain empty 
and contracted."^ Even, too, when the patient is 

* This may seem incompatible with the account given at page 479, 
of the mode of distingiiishino; a varicocele from a hernia; hut such is 



493 VARICOCELE. 

standing, and the veins are full, if firm pressure be 
made on the cord, the vessels below being thus re- 
lieved of the superincumbent weight of the blood, will 
gradually become emptied of their contents. It was 
natural, therefore, to conclude that if the pressure 
could be steadily continued for a sufficient length 
of time, it would enable the vessels to recover from 
the morbid state of dilatation in which they were 
previously retained by the hydrostatic pressure of 
the blood. In the case of the varix in the leg, it is 
clear that the local pressure could have had no 
effect on the artery by which the vein was supplied, 
and we may reasonably conclude that the blood in 
the veins below the point of compression found its 
way back to the heart by collateral and healthy 
channels. When the spermatic vessels are com- 
pressed in the manner just described, the pressure 
does not appear to be sufficient to obstruct the 
spermatic artery ; whilst the blood in the vessels 
below the part compressed no doubt returns by the 
smaller vessels, a sufficiency of which always exists 
in these cases in an adequately healthy state for the 
purposes of the circulation. The object, then, of 
this method of treatment may be stated to be — the 
maintenance, whilst the patient is in the upright po- 
sition, of such a degree of pressure on the spermatic 
veins as may be sufficient to relieve them from the 
superincumbent weight of the blood, without at the 
same time endangering the integrity of the testis by 

not the case, since for the latter purpose a much less degree of pressure 
oa the veins is required than to produce the effect described in the 
text. 



VARICOCELE. 497 

obstructing the spermatic artery, and without caus- 
ing so much uneasiness as to render the remedy as 
painful as, or more difficult to be borne, than the dis- 
ease. This pressure must be continued a sufficient 
time to enable the coats of the vessels to return to 
their natural dimensions, and to acquire strength to 
carry on the circulation. When this is effected the 
patient is cured. It is obvious, therefore, that the 
main difficulty of this treatment consists in the ap- 
plication of continuous local pressure. The only 
part where this can well be made on the spermatic 
veins is at the external abdominal ring ; but the 
force required is such, that unless it be skilfully 
applied patients are unable to submit to it. Two 
cases have been mentioned to me in which it was 
tried, but the instrument caused so much pain and 
inconvenience that the patients were obliged to dis- 
continue its use. In the following case of varicocele 
successfully treated by compression, for which lam 
indebted to my friend Mr. Daldy, he had recourse 
to a truss, which appears calculated to meet the 
exigencies of this mode of treatment better than 
any other mechanical contrivance with which I am 
acquainted, — F. U., cet. 21 , who had been the subject 
of varicocele, attended with a sensation of dragging 
and weight from the loins, for four years, at length 
became alarmed by the increase of the varix and 
the diminution of the left testis, which was reduced 
to about half the size of the right. At that period, 
now a twelvemonth ago, Evans's patent truss was 
applied to the external abdominal ring ; and at the 
present time, no other means having been used, 

63 



498 , VARICOCELE. 

the varix has disappeared, the pain has subsided, 
and the left testis has resumed its natural size, no 
appreciable difference now existing between the 
two. The truss has not yet been discontinued ; as 
some slightly distended veins, on a careful ex- 
amination, may still be felt above the testis. Mr. 
Daldy remarks, '* It appears to me that I gained 
considerable advantage in the treatment of this 
case by the use of Evans's patent lever truss, as the 
patient was enabled to wear it without the slightest 
inconvenience, and to regulate the pressure at will, 
so that he never suffered any pain from it." He I 
was induced to adopt this treatment in the case in ' 
consequence of a gentleman of his acquaintance, 
twenty-seven years of age, who was affected with a 
rapidly-increasing varicocele, having been recom- 
mended by Mr. Key to have recourse to pressure 
on the spermatic vein by means of a truss. He 
wore it for two months, and clearly derived benefit 
from it ; when he quitted the country for Canada, 
since which no intelligence has been received of 
the case. 

The truss employed in the above case certainly 
appears to possess many important advantages. 
Being made without any circular spring, it is not 
so liable to be displaced as the ordinary trusses. 
The lever spring enables the patient readily to regu- 
late the pressure of the pad, to increase or diminish 
it as may be necessary ; whilst the pad itself, being 
stuffed with a material^ of remarkable lightness and 

* This substance, called " moc-main," is the produce of the silk 
cotton tree, Bombax heptaphyllum, a plant which grows abundantly in 
the East Indies. 



I 



VARICOCELE. 499 

elasticity, allows of the application of greater force 
than could be tolerated under other circumstances. 
4. Excision of the Spermatic Veins. — This opera- 
tion has been practised by Petit and other surgeons. 
It is performed in the following manner. An as- 
sistant first separates the vas deferens, which he is 
to hold firmly and carefully between his thumb 
and forefinger. An incision from two to three 
inches in length is then made in the integuments 
over the cluster of dilated veins. The veins which 
then protrude are excised with a pair of curved 
scissors, or divided with a bistoury, first above and 
then below. If any troublesome haemorrhage after- 
wards ensue, the bleeding vessels are secured by 
ligature. A needle and ligature are sometimes passed 
under the veins at the upper part of the wound, in 
order to secure them from retraction after their 
division. The wound is closed by a single suture 
and adhesive plaister ; it often heals by the first 
intention. Dr. Warren states that he has been in 
the practice of doing this operation for a number of 
years ; that he has found it give great relief; that 
in no instance has it been necessary to repeat it ; 
and that it has never been attended with unpleasant 
consequences, except in a single instance. In that 
case, bleeding ensued after the operation, from 
which the scrotum became so enormously distended 
that it caused inflammation and sloughing of the 
cellular membrane and testicle ; after which the 
patient recovered.* 

* Surgical Observations on Tumours, p. 441, 



500 VARICOCELE. 

This is a more severe operation than the ligature, 
and it is equally, if not more liable, to be followed 
by phlebitis and wasting of the testis ; and besides is 
attended with risk of haemorrhage, and the produc- 
tion of a considerable and troublesome suppurating 
wound- 



In the treatment of cases of varicocele, the sur- 
geon should bear in mind that as the complaint is 
not dangerous, seldom produces pain amounting 
to more than an inconvenience, and usually admits 
of relief by palliative means, it is not justifiable in 
ordinary cases to risk the loss of the testis, or to 
perform severe operations for its removal. For this 
reason, ligature and excision of the veins, and such 
operations as are severe or at all liable to induce 
phlebitis, are never resorted to by judicious and 
cautious practitioners, except in the few instances 
in which palliative means fail to afford relief and 
arrest the decay of the testis, and the pain and 
annoyance are really so great as to require some- 
thing to be done to alleviate the patient's sufferings. 
The indication for the perfect cure of varicocele is 
not merely to aid and support the dilated and 
weakened vessels, but so far to relieve them of the 
superincumbent weight of the blood as to enable 
them to return to their natural dimensions, and 
recover their tone so as duly to carry on the circu- 
lation. The first indication may be fulfilled to a 
certain extent by the suspensory bandage, and in » 
some cases permanently by the excision of a portion 
of the scrotum ; and in mild cases these plans are 



VARICOCELE. 601 

sufficient to give all the relief required, and to 
prevent the extension of the disease : the latter 
proceeding may be resorted to whenever the patient 
is tired of wearing a bandage, and is willing to 
submit to an operation which, though painful, is not 
under ordinary circumstances attended with danger. 
But neither artificial support, nor excision of the 
scrotum, is capable of fulfilling the second indication 
— of reducing the size and thickened coats of the 
dilated veins. The only plan which appears to be 
fully adapted to effect this object is firm, steady, 
and continued pressure on the spermatic veins at 
the ring by means of a well-adjusted truss. At 
present our experience of this mode of treatment is 
too limited to admit of any opinion of its efficacy 
being confidently expressed ; but I look with no 
slight interest to the result of further trials of a 
remedy which seems to me to be based on sound views 
of the pathology of the disease. This plan appears 
to be particularly applicable to cases of varicocele 
in young persons, whose reparative powers would 
be sufficient to restore the veins when relieved of 
pressure to a healthy state. In acute or severe 
cases of varicocele, when the distress is considerable, 
or the symptoms partake of a neuralgic character, 
and when the methods of treatment just alluded to 
fail in affiDrding sufficient relief, it may become ne- 
cessary to have recourse to the ligature for the 
obliteration of the varicose veins ; and as in these 
cases life is embittered by the disease, the patient 
being incapacitated by it from earning a livelihood, 
and that too at an early age, it would certainly be 



50 2 VARICOCELE. 

justifiable in such cases to incur the slight hazard 
of phlebitis incidental to the ligature, and to risk 
even the loss of the testis, which would undoubtedly 
suffer if the disease continued, in order to obtain 
the relief and comfort which the operation is cal- 
culated to afford. The plan adopted in the case 
reported at page 492, is the one to which I should 
be inclined to give the preference ; for, with the 
ingenious tourniquet devised by Mr. Luke, the sur- 
geon has it readily in his power to tighten or relax 
the constriction as the circumstances of the case 
may require ; and no treatment could have been 
milder than the ligature thus applied in the case 
related. An important point supposed to be gained 
by this mode of treatment, is the effect of the gentle 
pressure first produced in exciting sufficient irri- 
tation to cause obliteration of the veins before the 
constriction afterwards made by tightening the 
ligature cuts the vessels through ; by which means 
the risk of phlebitis is in a great degree, if not en- 
tirely obviated, the ligature acting in fact on an 
impervious cord instead of on a tubular canal. 
The ligature should be applied as high up as pos- 
sible ; for the plexus of enlarged veins is small 
above, and increases in size towards the testis. I 
should never, however, recommend the application 
of a ligature to the veins in a person far advanced 
in life or not in a good state of health ; for the sur- 
geon cannot, under the best of circumstances, divest 
his mind of all fear of the occurrence of inflamma- 
tion of the veins. 

In some of the cases which have been operated 
on by ligature the testis has not been found to 



ADIPOSE TUMOURS OF THE SPERMATIC CORD. 503 

suffer. In these instances, no doubt, some of the 
veins — for it is difficult to include them all — espe- 
cially the plexus running close to the vas deferens, 
had escaped the effects of the ligature, and proved 
sufficient to return the blood from the testis. Such 
appeared to me to have happened in the case v^hich 
I have detailed. Hence it becomes a question 
whether the surgeon should endeavour to include 
all the spermatic plexus in the ligature, or be satis- 
fied with tying only a part of the veins ; since, by 
including the whole, the loss of the testis, which is 
of importance at the period of life that this disease 
occurs, is very likely to result.^ It may, however, 
be objected to the latter plan, that the attempt 
would only increase the risk of the operation fail- 
ing, without insuring sufficient means of circulation 
to preserve the integrity of the testis ; but upon 
this point further experience is required. 



CHAPTER II. 

ADIPOSE TUMOURS OF THE SPERMATIC CORD. 

I HAVE already treated, under the head of Hydro- 
cele, of the serous cysts occasionally developed in 
the course of the spermatic cord. This part may 

* In the unfortunate case in which Delpech tied the spermatic veins, 
atrophy of both testes resulted. I have heard of other instances in 
which the gland has wasted after operations for the obliteration of the 
veins. It is not improbable that in some of these cases the spermatic 
arterv was also included in the ligature. 



504 ADIPOSE TUMOURS OF THE SPERMATIC CORD. 

also be the seat of abnormal depositions of fat. 
They generally occur in persons advanced in life. 
The adipose matter is formed in the loose cellular 
tissue, and is often interposed between the parts 
composing the cord. It occurs at different parts of 
the spermatic cord, as high up as the inguinal canal, 
and as low down as the epididymis. In examining 
the testes of a young man who died of pleurisy in 
the London Hospital, I found a quantity of fat along 
the cord and around the epididymis, and some also 
beneath the tunica vaginalis reflexaon the posterior 
part of the testis. I have lately met in another 
case with some small isolated masses of fat, coupled 
with a small encysted hydrocele of the cord. Mor- 
gagni in one instance met with a similar deposition 
extending to the testis.^ He also remarks, " On 
one occasion when the testis was enlarged, I found 
a little fat deposited within the innermost substance, 
which, in other respects, was not much diseased. 
From this case I inferred that tumours of the testis 
may occasionally originate from an unnatural gene- 
ration of fat, and its subsequent increase."t 

When fat is developed in the cord in considerable 
abundance, it sometimes forms, in front of the sper- 
matic vessels, a loose and movable tumour, having 
the soft doughy feel and lobular character of ordi- 
nary adipose swellings. These accumulations of 
fat occasion no inconvenience, and consequently do 
not require any surgical treatment. They have, 
however, been mistaken for omental hernia. Pel- 
letan, by whom they have been noticed, speaks of 

* Cooke's Morgagni, vol. ii. p. 435. f Ibid. p. 437. 



ADIPOSE TUMOURS OF THE SPERMATIC CORD. 505 



them under the denomination of " hernie grais- 
seuse"^ I once dissected a lobulated 
fatty tumour, surrounded by the 
thickened sheath of the spermatic 
cord, on the body of a man upwards 
of eighty years of age, which was 
very similar in appearance to a por- 
tion of omentum contained in a her- 
nial sac. It is represented in the 
annexed wood-cut. Cloquet has also 
given an account of the dissection 
of a fatty tumour, found in the left 
spermatic cord of an old man, which 
resembled an irreducible epiplocele.t 
Mr. Macilwain mentions an instance 
in which it was thought proper to 
cut down upon a tumour of this kind 
in the spermatic cord to ascertain its 
nature, in consequence of the patient 
labouring under the symptoms of 
strangulated hernia. The surgeon, finding the 
fatty tumour to be so intimately connected with 
the cord as not to admit of extirpation without 
injury to it, removed tumour, testicle, and allf — 
a proceeding which, in such a case, could scarcely 
have been justifiable. These swellings have the soft 
inelastic feel, elongated form, and indolent character 
of an irreducible omental hernia. In a case, there- 




* Clinique Chirurgicale, t iii. p. 33. 

t Recherches sur les Causes et I'Anatomie des Hernies Abdomi- 
nales, p. 26. 

I Surgical Observations, p. 291, note. 

64 



506 SPASxM OF THE CREiMASTER MUSCLE. 

fore, where obstinate constipation and other symp- 
toms of strangulated hernia exist, if after a careful 
examination of the tumour, and an attentive con- 
sideration of the history of the case, any question 
remain respecting its nature, it would be quite 
right to remove all doubt by cutting down upon 
the part. 

Fatty deposits in the spermatic cord might easily 
be mistaken for a varicocele ; and some tact and 
experience are required to distinguish the peculiar 
swelling caused by the dilated veins from a soft, 
inelastic, indefined adipose tumour. The latter is 
constant, whilst varicocele diminishes or disappears 
in the recumbent position, 

Ossific tumours have in some rare instances been 
observed in the spermatic cord. In the London 
Hospital Museum there is a preparation of a stone, 
the size of a small walnut, in the cellular tissue at 
the upper part of the spermatic cord of a man who 
died of strangulated hernia. 



CHAPTER III. 

SPASM OF THE CREMASTER MUSCLE. 

Spasm of the cremaster muscle is an occasional 
symptom in different affections of the urinary or- 
gans. It occurs in diseases of the kidney and in 
the passage of a calculus down the ureter, and also 
in affections of the prostatic portion of the urethra. 



SPASM OF THE CREMASTER MUSCLE. 507 

being the result of irritation transmitted froni 
these parts. In the two first cases, it may be 
explained by the connexion which exists between 
the spermatic plexus of nerves and the renal, and 
in the latter one by the connexion of the same 
nerves with the hypogastric plexus along the vasa 
deferentia. The spasm comes on suddenly ; so that 
the testes are forcibly drawn up and retained, 
whilst it lasts, at the external abdominal rings, 
the patient suffering more or less pain. This 
affection is to be treated with the warm bath, fo- 
mentations of hops or poppyheads^ opiates, &c., 
attention being at the same time paid to the source 
of irritation. In the following case spasm of the 
cremaster muscle, of a mild character, appeared to 
be the result of an injury, — A Jew boy, aged 
eleven, applied to me at the London Hospital, on 
account of an uneasy state of the testes. They 
were retracted to the external abdominal rings, 
producing a deep vi^inkle across the pubes. The 
scrotum was flaccid and empty. It appeared that 
a short time before he had received a kick on the 
pubes, since which the testes had become drawn 
up. Pressure on the pubes gave pain, and when 
made at the part where the cremaster is attached 
the testis immediately descended, but was again 
elevated as soon as the pressure was remitted."* 
Conceiving that the spasm was chiefly owing to 
sligkt inflammation at the seat of injury which 

* I once observed the same eircumstance in a case of spasmodic 
retraction of the testes, symptomatic of irritation at the prostatic 
part of the urethra. 



508 SPASM OF THE CREMASTER MUSCLE. 

had affected the internal attachment of the cre- 
master, I ordered leeches to the part, fomentations, 
and mild aperients. No relief followed this treat- 
ment. The cold douche was then applied, with 
the effect of causing the muscle immediately to 
relax. The spasm returned soon afterwards, but 
not to the same extent as before. The douche 
was repeated with the same effect, and the boy 
ceased to attend. He came to me again, some 
months afterwards, with gonorrhoea and a return 
of the spasm in the cremaster, which subsided as 
the disease in the urethra became relieved. 



PAET IV. 

DISEASES OF THE SCROTUM, 
CHAPTER I. 

INJURIES OF THE SCROTUM. 

The scrotum is exposed to contusion and lacera- 
tion from external violence. Contused wounds of 
the scrotum are chiefly remarkable on account of 
the large quantity of blood generally effused be- 
neath the skin. The cellular tissue, like that of 
the eyelids, is exceedingly loose, so that a slight 
blow produces rupture of vessels and abundant 
ecchymosis. The swelling which arises is consider- 
able : the testes become surrounded with so much 
blood that they cannot be felt, and the skin in a 
few days assumes a deep purple hue. These cases 
generally do well ; but some weeks elapse before 
the blood is all absorbed, and the swelling and 
discoloration are completely removed. All that 
is usually necessary in the way of treatment, pro- 
vided the testes have escaped injury, is rest, support 
to the swollen scrotum with a bandage or pillow, and 
the application of a cold evaporating lotion. A 
lotion composed of the hydrochlorate of ammonia, or 
a poultice of oatmeal and vinegar, appears to accele- 
rate the absorption of the effused blood. When the 



510 DISEASES OF THE SCROTUM. 

contusion is severe and the extravasation consider- 
able, inflammation sometimes arises, and even termi- 
nates in suppuration or mortification ; but this is 
a rare result of such injuries, and only follov^^s in 
persons of impaired constitution. In a case of the 
kind, after gangrene or suppuration has taken place, 
the scrotum should be relieved by free incisions. 
Under other circumstances this operation is highly 
objectionable, and must never be resorted to for 
the relief merely of the extravasation, as incisions 
are very liable to be followed by sloughing of the 
cellular tissue and severe constitutional symp- 
toms. 

Lacerations of the scrotum, though formidable in 
appearance, usually terminate favourably. There 
is not much haemorrhage ; but, ov\r^ing to the con- 
tractile nature of the integuments, the scrotum 
presents a large gaping wound. This must be 
cleansed, the coagula removed, and the edges 
brought together and retained by sutures and ad- 
hesive plaister. The wound heals in general very 
readily. — I was sent for to see a man who, in a 
state of intoxication, had sustained an injury of the 
privates by sitting down upon the broken arm of a 
chair. I found a large triangular lacerated wound 
on the left side of the scrotum, the edges of which 
were so far separated that the part appeared as if 
a great portion of the integuments had been re- 
moved, the whole of the left testis and part of the 
spermatic cord being completely exposed and pro- 
jecting. The edges of the wound were without 
difficulty immediately closed with sutures : they 



PRURIGO SCROTI. 611 

united by the first intention, and in a week the 
part had completely united and the patient was 
cured. 

The scrotum is not very often injured by burns 
or scalds, the part being protected by a woollen 
dress. — A deaf and dumb man, at work at a soap- 
boiler's, fell into a vat containing caustic potass of 
the strength of 10 per cent. He was admitted 
into the London Hospital shortly after the acci- 
dent. The skin was denuded of cuticle, and su- 
perficial sloughs were produced on the face and 
hands ; but his chief sufferings arose from the 
action of the caustic on the prepuce and scrotum, 
which were entirely excoriated and a good deal of 
the skin destroyed. The sloughs separated and 
the sores healed in about three weeks, the scrotum 
being slightly contracted. 



CHAPTER 11. 

PRURIGO SCROTI. 



The scrotum is sometimes the seat of an intolerable 
itching, which produces much distress, tormenting 
the patient by day and disturbing his rest by night, 
and thus whilst it lasts rendering his life truly 
miserable. This complaint is commonly accom- 
panied with the formation of a number of round 
flattened papulag of a slight red colour, which are 
readily recognised on the dull and darker surface 



512 PRURIGO SCROTI. 

of the scrotum. The skin becomes excoriated by 
the patient scratching himself; which, though pro- 
ductive of temporary relief, aggravates his suffer- 
ings afterwards. There is often a disagreeable 
discharge from the sebaceous follicles ; and after 
the complaint has existed for some time the skin 
becomes browner than in its natural state, and 
somewhat thickened. The irritation comes on in 
paroxysms: it is increased by exercise, especially 
in warm weather, and by the heat of the bed at 
night, and it is liable to extend towards the anus 
and down the inside of the thighs. 

This affection attacks adults ; but occurs gene- 
rally to persons in advanced life, and is supposed 
to be induced by inattention to cleanliness. It is 
a very obstinate complaint, often resisting every 
kind of treatment for months, and even years, 
though liable to complete remissions and frequent 
relapses at variable intervals. 

Treatment. — Very little relief is afforded in this 
affection by internal remedies. The bowels should 
be occasionally acted on by saline purgatives. It 
has appeared to me that benefit has been derived 
in some cases from 3ss. to 3J. of the sulphate of 
magnesia dissolved in the infusion of roses, with 
fi\e or six minims of the dilute sulphuric acid, 
given three times a day. If the general health 
should suffer from want of rest at night, as some- 
times happens, the acetate or muriate of morphia 
may be taken at bedtime. Alteratives, as five grains 
of the Pil. Hydrargyri Chloridi Comp., given daily or 
every other day, will tend to correct the state of the 



PRURIGO SCROTI. 513 

secretions, which are often disordered in this affec- 
tion. 

The patient should be enjoined to refrain from 
scratching the parts ; his dress should be light and 
loose ; and he ought to avoid exercise in warm 
weather and a stimulating diet. A warm bath 
should be taken two or three times a week, as it 
promotes cleanliness, which is very essential in 
these cases. The parts ought to be kept cool with 
a lotion of vinegar and water, or of the bichloride 
of mercury, in the proportion of two grains to the 
ounce of water. The yellow wash, and lotions 
composed of the carbonate of potass in the propor- 
tion of four drachms to twelve ounces of rose water, 
have also proved of service. I have found the 
Unguentum Hydrargyri Nitratis DiL, smeared over 
the scrotum at night, one of the most efficacious 
applications for diminishing the itching. Sulphur 
ointment and sulphureous vapour baths sometimes 
succeed in affording relief Local cinnabar fumi- 
gations, applied by means of an apparatus adapted 
for the purpose, have been strongly recommended 
by M. Biett in this troublesome and distressing 
complaint."* 

* Cazenave et Schedel, Abrege pratique des Maladies de la Peau, 
edit. 3eme, p. 315. 



65 



514 VARICOSE VEINS OF THE SCROTUM. 

CHAPTER III. 

VARICOSE VEINS OF THE SCROTUM. 

Some authors have noticed, amongst the diseases 
incidental to the scrotum, a varicose condition of 
its veins. The veins, however, of this part are 
never weakened and dilated to a degree sufficient 
to require the attention of the surgeon. The re- 
markable contractility of the dartos contributes to 
their support, and to diminish the tendency to 
dilatation. Varix of the spermatic veins com- 
mences much more commonly in young men than 
in old ; whereas, in consequence of the lax state of 
the scrotum in advanced life, the scrotal veins 
more frequently become varicose at that period. 
In old men they sometimes present a curious ap- 
pearance, the scrotum being studded with a number 
of minute red or black spots, about the size of a 
pin's head, and sometimes larger, evidently dilata- 
tions of the small veins, as they disappear for a 
time under gentle pressure of the finger. I have 
occasionally observed them when the scrotum has 
been distended by a hydrocele. In severe cases of 
varicocele the veins of the scrotum sometimes par- 
take in the dilatation of the vesselsof the spermatic 
cord. 



PNEUMATOCELE. (EDEMA SCROTI. 615 

CHAPTER IV. 

PNEUMATOCELE 

Is a term employed to designate a distended state 
of the scrotum from the presence of air in its loose 
cellular tissue, which is treated of by old writers on 
surgery as an affection of no uncommon occurrence. 
Emphysema of the scrotum, however, is only seen 
in the present day when produced by artificial in- 
flation ; a trick of feigning disease sometimes prac- 
tised by soldiers, and by others for the purpose of 
imposing on the charitable. The scrotum has been 
inflated to the size of a child's head ; a degree of 
distension which is borne without any injurious 
consequences. The nature of the tumour can be 
readily detected by the crepitation of the part under 
the finger. 



CHAPTER V. 

(EDEMA SCROTL 



The cellular substance of the scrotum being loose, 
abundant, and free from fat, and the skin plentiful 
and very extensible, this part undergoes a more 
remarkable degree of distension from oedema than 
any other part of the body ; and, owing to the pen- 
dent position of the scrotum, oedema of this part is 



516 (EDEMA SCROTI. 

often met with, occurring generally as a symptom 
of organic disease, in conjunction with serous infil- 
tration of the extremities or body at large. (Ede- 
ma of the scrotum, termed by some writers ana- 
sarcous hydrocele, occasionally occurs, however, as 
a distinct aifection, or independently of oedema in 
other parts. 

On cutting into the scrotum when thus affected, 
the cellular tissue is found loaded with a white or pale 
straw-coloured transparent serum, which readily 
drains off through the opening. The cells are dis- 
tinctly seen of large size, some of them being ca- 
pable of admitting the extremity of a goose's quill, 
or even of the little finger. The testes are wholly 
surrounded with the serous infiltration : the vagi- 
nal membrane covering them is found to be loosely 
attached amidst the cellular tissue. The blood- 
vessels appear small, indistinct, and few in number. 

Symptoms. — The oedema commences at the most 
depending part of the scrotum, to which it is con- 
fined when the infiltration is slight. When the 
whole scrotum is involved, the part presents an 
uniform, indistinctly defined tumour, with a soft 
and doughy feel, and pits on pressure ; but, owing 
to the large size of the cells, the fluid traverses the 
cellular tissue so freely that the parts retain the 
impression of the finger for but a few moments. 
As the tumefaction increases the tegumental rugae 
are obliterated, and the surface of the skin becomes 
smooth and somewhat tense, and has a pale, glisten- 
ing, semi-transparent appearance. The testes are 
so surrounded with the infiltrated serum that they 



(EDEMA SCROTI. 517 

cannot be distinguished. When the oedema is con- 
siderable, the integuments of the penis generally 
participate in the distension : the prepuce becomes 
twisted and distorted, and so enlarged as to conceal 
the glans penis. The tumefaction often extends also 
to the groins and lower part of the abdomen. 

(Edema of the scrotum is occasioned by the vari- 
ous causes obstructing the circulation and producing 
dropsical effusion in other parts ; and, owing to the 
depending position of the scrotum, it is usually one 
of the parts first distended in general dropsy. It 
is observed occasionally as a local affection in old 
men, and in persons debilitated by disease, espe- 
cially where the scrotum is particularly pendent. 
It is sometimes seen in children shortly after birth, 
and is produced by disease of the inguinal glands, 
and by tumours obstructing the course of the veins 
and lymphatics. It is occasionally caused by the 
accidental rupture of a hydrocele of the tunica 
vaginalis, and in the attempt to cure this disease 
by acupuncture. 

Diagnosis. — The symptoms presented by oedema 
of the scrotum are of so marked a character, that 
this affection is not readily confounded with any 
other disease, and when the dropsy is general it is 
scarcely possible that any error can be committed. 
Local oedema may, however, be mistaken for a 
hydrocele, and when of great extent for elephanti- 
asis of the scrotum. In oedema the tumefaction is 
soft and diffuse, pits on pressure, occupies both 
sides of the scrotum, and conceals both testes : in 
hydrocele it is resisting, defined, and fluctuating. 



518 (EDEMA SCROTI. 

and confined to one side ; except in double hydro- 
cele, in which case there is no similitude to oedema, 
as there are always two well-defined and distinct 
tumours on the two sides of the scrotum. Pott 
once operated on an oedematous swelling of one 
side of the scrotum, having mistaken the case for a 
hydrocele. — A man, aet. 45, showed him a swelling 
on the left side of the scrotum, which was large, 
full, tight, and had all the symptoms of a hydro- 
cele ; viz. fluctuation, freedom of the upper part 
of the process, and concealment of the testicle. 
Thinking himself clear in the true nature of the 
disease, he without scruple pierced it with a small 
trocar in the lower and anterior part, and let out 
about two ounces of limpid water, but could not 
draw off any more. He withdrew the canula, and 
examined the swelling again, which was but little 
diminished, though altered in appearance. He 
could then plainly distinguish the testicle, and 
became convinced that the disease was (what he 
had never seen before) an anasarca of the scrotum 
on one side only, having a certain quantity of water 
in one cyst or bag, and the rest difiused through 
the cells in the usual manner: the latter made all 
the tumefaction, which remained after tapping ; 
and the former had concealed the testicle.* If 
this case had been narrated by a surgeon of less 
judgment and experience than Mr. Pott, we should 
be inclined to suspect that the tumour had origin- 
ally been a hydrocele, and that, when tapped, the 

* Chirurgical Works, 4to. p. 336. 



(EDEMA SCROTI. * 519 

fluid had partially escaped into and infiltrated the 
cellular tissue around the sac. The limitation of 
the oedematous swelling to one side of the scrotum 
was a very unusual occurrence ; for although the 
cellular tissue is usually somewhat condensed in the 
course of the septum, there is always a ready and 
free communication between the two sides. In this 
case the septum must have been particularly close 
and dense, and the cause of the dropsical effusion 
have operated only on one side. 

The smooth surface of the skin, the softness and 
laxity of the tumour, its ready retention of the 
impression of the finger, and its comparatively 
small size, are the characters by which oedema of 
the scrotum may easily be distinguished from ele- 
phantiasis. 

Treatment. — (Edema of the scrotum being in 
general only a symptom of disease elsewhere, and 
not of itself of any serious moment, seldom requires 
any separate or local treatment. When the tume- 
faction is very great, and the skin so tense that 
there is risk of its bursting or mortifying, the part 
must then be relieved by acupuncture. The cells 
so freely communicate with each other, that one or 
two punctures with a darning needle are sufficient 
to relieve the most bulky swellings. It was usual 
formerly to relieve the distended scrotum by inci- 
sions. But this is a dangerous practice ; for inci- 
sions are very likely to excite diffuse inflammation, 
which, in the weak state of the part and of the 
patient's powers, is speedily followed by mortifica- 
tion. Pott has recorded three cases in which exten- 



520 * DIFFUSE INFLAMMATION OF THE SCROTUM. 

sive mortification followed incisions of the scrotum 
for this complaint, one of which proved fatal.^ 



CHAPTER VI. 

DIFFUSE INFLAMMATION OF THE SCROTUM. 

Diffuse inflammation of the scrotum, though not 
particularly noticed by writers on surgery ,t often 
occurs as a distinct affection ; and, owing to modifi- 
cations in the texture of the integuments, the cha- 
racter of the disease diflers in some respects from 
that of diffuse inflammation in other parts. This 
affection is well known to practitioners of expe- 
rience, and is not unfrequently seen in hospital 
practice. It occurs under two forms. In one it is 
mild and unattended with danger, and terminates 
favourably under gentle antiphlogistic treatment. 
In the other form the complaint is severe and dan- 
gerous, and prompt and decisive measures are 
requisite to avert serious consequences. The first 
form occurs generally to persons at the adult period 
of life. The skin of the scrotum becomes affected 
with slight erythema ; assumes a faint rosy hue ; 
soon becomes shining, tense, and oedematous ; and 

* Lib. cit. Case VI. p. 365. 

t Some cases of this affection have been published by Mr. Listen, 
under the denomination of "Acute Anasarca of the Scrotum," in the 
twenty-second volume of the Transactions of the Medico-Chirurgical 
Society. 



DIFFUSE INFLAMMATION OF THE SCROTUM. 521 

quickly loses its rugous character. The light in- 
flammatory blush extends in a short time to the 
perineum and integuments of the penis, which also 
become tumid and oedematous ; and in some in- 
stances it spreads even to the groins, lower part of 
the abdomen, and inside of the thighs. Its appear- 
ance is accompanied with symptoms of slight fever, 
a hot skin, and furred tongue. This affection 
usually occurs to persons exhausted by fatigue and 
want of rest and nutriment. — A lad, twenty years 
of age, previously in tolerable health, who had 
walked up to London from a long distance in the 
country for work, and had fared badly on the road, 
applied to me on account of this affection, with 
which he 7/as seized the day after his arrival in the 
metropolis. — A labouring man who had been ex- 
posed to the inclemency of the weather, and had 
undergone a good deal of fatigue on board a barge 
in the river, was attacked in the same manner. I 
have seen it in weakly persons arise from slighter 
circumstances, and sometimes without any obvious 
cause. It is occasionally produced, especially in 
old people, by the irritation of the urine dribbling 
over the parts, and the lodgment of discharges 
and acrimonious fluids amongst the rugae of the 
scrotum. 

The second form of diffuse inflammation of the 
scrotum com^mences like the former ; but the dis- 
ease runs rapidly into mortification. The slight 
rosy hue of the scrotum soon becomes changed to a 
violet or livid colour, and ash-coloured or tawny 
spots appear at an early period on the most depend- 

66 



522 DIFFUSE INFLAMMATION OF THE SCROTUM. 

ing parts. These quickly extend, and, unless 
checked by decisive treatment, the whole scrotum 
soon becomes involved-; so that if the patient sur- 
vive, and the sloughs separate, the testes are entirely 
denuded of their integuments. The sloughing is 
attended with symptoms of a low typhoid charac- 
ter, a hot skin, feeble pulse, and a brown and dry 
tongue, under which the patient often sinks. This 
form of the affection attacks persons of a cachec- 
tic habit and broken-down constitution, or men 
enfeebled by age. It is produced by the same 
causes as the milder form ; but it is also liable to 
occur after a slight injury, and is often excited by 
disease of the urinary organs, as stricture, or an 
abscess in the perineum, independently of urinary 
extravasation. The following case is recorded by 
Mr. Liston. — W. R., aged forty, admitted into 
Royal Infirmary, July 21st, 1834. Received a 
kick on the perineum from a cow about a fortnight 
ago. There was much pain at the time ; but the 
injury was followed by no further inconvenience 
until about eight days ago, when the pain returned, 
and was followed by considerable and rapid swell- 
ing of the scrotum. Upon examination the scrotum 
was found to be much swelled and extremely tender. 
At the lower part it was of a dark livid colour ; and, 
on pressing it, an emphysematous crackling was 
distinctly felt. There was little swelling in the 
perineum ; but on the right side, about an inch 
anterior to the rectum., there was a small opening, 
irregular in its appearance, through which the dead 
cellular tissue protruded, and a small quantity of 



DIFFUSE INFLAMMATION OF THE SCROTUM. 523 

what was, at first, believed to be urine, escaped. 
The pulse was small and rapid ; the tongue dry in 
the centre and moist round the edges. Bowels 
reported open ; and states that he passes his urine 
freely. Immediately after his admission free inci- 
sions were made into the scrotum, and the opening 
in the perineum enlarged. In both places the cel- 
lular tissue was found in a state of gangrene ; and 
a considerable quantity of thin foetid fluid, mixed 
with air, escaped from the scrotum. The man was 
a habitual drunkard and of weak intellect. He 
gradually sunk and died on the 28th of July, before 
the sloughs had separated. On dissection, the 
whole urinary apparatus was found in a perfectly 
healthy state."* 

It is a remarkable circumstance, that inflamma- 
tion of the scrotum rarely terminates in the eflusion 
of lymph or pus. It seems that the pressure con- 
sequent upon the abundant effusion of serum is 
sufficient to arrest the circulation, and occasion 
mortification before other changes ensue. When 
suppuration takes place it is generally in the dif- 
fused form, though the matter has a tendency to 
collect at the most depending part of the scrotum. 
I have rarely met with a well-formed abscess in this 
part unconnected with suppuration in the perineum 
or with disease of the urethra. 

Diagnosis. — Diffuse inflammation of the scrotum 
may be confounded with oedema ; but differs from 
it in the more active character of the disease, in the 

f' Lib. cit. p. ,293. 



624 DIFFU&E INFLAMMATION OF THE SCROTUM. 

inflammatory redness of the skin, and the general 
febrile disturbance which accompanies it. 

Treatment. — In the milder form of this affec- 
tion gentle purgatives, antimonials to determine to 
the skin, and rest in the recumbent position for a 
few days, with the application of an evaporating 
lotion to the scrotum, which should be well elevated 
on a pillow placed between the thighs, are gene- 
rally all that is required to subdue the inflammatory 
action, and cause the swelling to subside. When 
there is much tension, warm fomentations are pre- 
ferable to cold applications. It is bad practice to 
apply leeches in these cases, as they are very liable 
to induce sloughing. If gangrene be apprehended, 
punctures with a lancet should be made in the 
scrotum at its most depending part, to allow the 
serum to escape, and thereby remove the tension. 
Nothing succeeds so speedily and effectually in 
averting the sloughing process as early incisions. 
They must not be merely skin-deep, but the dis- 
tended cellular tissue beneath should also be divided. 
They need not, however, be very extensive, as one 
or two small openings well placed will be sufficient 
for the relief of the tension. Incisions are very 
painful, and when large produce a considerable 
shock to the nervous system ; which the patient, in 
his weakened state, is not well able to bear. It is 
also of great moment to avoid the loss of blood : 
consequently, if bleeding ensue from any of the 
divided vessels, an active assistant should be at 
hand to place his fingers upon them, and restrain 
the haemorrhage by pressure. These vessels pour 



MORTIFICATION OF THE SCROTUM. 525 

out blood profusely when first divided ; but they 
soon contract, and do not in general require liga- 
tures. There is often a free oozing from the skin 
generally, which may be checked by the application 
of small dossils of dry lint. The parts are to be 
treated after they have been incised with fomenta- 
tions, water dressings, or light poultices. In this 
dangerous form of the disease the powers require 
to be supported by quinine, ammonia, wine, and 
brandy, and a nourishing diet. The diffuse inflam- 
mation v^^hich occurs in connexion with stricture 
or perineal abscess usually subsides as soon as the 
obstruction is overcome, the matter discharged, and 
the exciting cause removed. Where this is ne- 
glected, the mortification which ensues adds greatly 
to the danger and urgency of the case. 



CHAPTER VII. 

MORTIFICATION OF THE SCROTUM. 

Mortification of the scrotum is commonly the 
result either of the worst form of diflfuse inflamma- 
tion just described, or of urinary extravasation, 
and it sometimes occurs at the close of exhausting 
fevers. It would be out of place to treat here of 
the subject of urinary eflusion. It will be sufficient 
to remark that the eflect of the irritating fluid dif- 
fused throughout, and distending the cellular tissue 
of the sciotum, is soon to excite inflammation and 



526 MORTIFICATION OF THE SCROTUM. 

produce the death of all the parts with which it 
comes in contact, unless such a result be speedily 
averted by deep and pretty free incisions, so as 
completely to relieve the distension and allow the 
urine to drain off from every part of the scrotum. 

The scrotum is so situated, protected by and re- 
ceiving the warmth of the thighs, and at no great 
distance from the centre of the circulation, and at 
the same time is so well supplied with blood-vessels, 
that it is a part by no means exposed to mortifica- 
tion from deprivation of animal heat. Amongst 
the numerous cases of frost-bites which have come 
under my notice, I have only w^itnessed one in 
which the scrotum had suffered from this cause. 
The spots were very small, and after the separation 
of the superficial sloughs the sores soon healed. 
Sir A. Cooper has recorded the following case. — A 
patient in Guy's Hospital, who was in the retreat 
with the Duke of York's army in the Netherlands, 
and exposed to excessively severe cold, had his 
scrotum become frostbitten, and sloughed away, 
exposing the tunica vaginalis and tendon of the 
cremaster muscle, which were, when he was in the 
hospital, covered by granulations, but had not a 
new scrotum formed. The slough had extended 
to the penis, and divided the vessels of the penis, 
which was swollen to an enormous size.* 

Treatment. — Sloughing of the scrotum, from 
whatever cause it may proceed, is seldom free from 
danger, being attended in most instances with a 

* Lib. cit. p. 20. 



MORTIFICATION OF THE SCROTUM. 527 

failure of the powers of life and low febrile symp- 
toms, which require to be counteracted by stimu- 
lants. The local treatment, after free incisions 
have been made, consists in the application of fo- 
mentations and light poultices, which may be 
moistened with the Liquor Calcii Chloridi, to 
correct the offensive foetor. In many cases the 
extension of gangrene can be arrested and the 
powers rallied by judicious treatment ; and then 
the process of separation and detachment of the 
dead parts soon commences, and, as would be 
expected from the vascularity of the scrotum, pro- 
ceeds with activity. Large sloughs come away, 
leaving behind an extensive, open, and formidable- 
looking sore, with the testes and spermatic cords 
completely denuded. Fortunately there is no part 
of the body in which the reparative efforts of na- 
ture are more remarkably displayed after extensive 
mortification than in the scrotum. In cases in 
which the whole scrotum and even part of the 
integuments of the penis have sloughed away, gra- 
nulations have rapidly sprung up from the exterior 
of the tunica vaginalis and proper investments of 
the cords ; cicatrization has taken place all around 
from the edges of the wound ; and partly by liberal 
demands upon the integuments of the pubes, groins, 
and perineum, and partly by the production of new 
skin, the exposed testes and spermatic cords have 
become invested with a new covering adequate 
for the protection of these important organs. The 
new scrotum is not exactly like its predecessor ; it 
is thin, tense, and without colour, and closelv in- 



528 ELEPHANIIASIS SCROTI. 

vests the testes; and sometimes, when there is 
much contraction of the cicatrix, these glands are 
forced upwards into the groins. In these cases the 
surgeon can do but little to aid and promote the 
efforts of nature. He has only to apply mild and 
simple dressings, and to avoid unnecessary med- 
dling. Officious interference by sutures, plaisters, 
and bandages for the purpose of approximating 
the edges of the wound, avails very little in accele- 
rating the healing process. 



CHAPTER VIII. 

ELEPHANTIASIS SCROTI^ 



Elephantiasis is a disease of the scrotum occasion- 
ing a remarkable tumour; it is rarely seen in 
Europe, but is of very common occurrence in many 
other parts of the globe. As I have never wit- 
nessed a case of this affection, the following de- 
scription is taken from an examination of some of 
the tumours removed by operation, which have been 
preserved, and from the accounts of elephantiasis 
given by the best writers on the subject. 

Elephantiasis consists in a morbid thickening of 
the tissues of which the scrotum is composed. The 
epidermis becomes thickened, rough as in icthyosis, 
and intersected with fissures or chaps. The chorion 
is immensely consolidated, and often nearly an inch 
in thickness, and very dense. The chief bulk, how- 



ELEPHANTIASIS SCROTI. 529 

ever, of the tumour is formed by the conversion of 
the loose cellular tissue of the scrotum into a large 
mass of fibro-cellular tissue, infiltrated with a thick 
jelly-like fluid, evidently albumen, as it coagulates 
on the application of heat, acid, or alcohol, and some- 
times on cooling, after its removal from the body. 
The areolae of this tissue vary a good deal in size, 
but some of them have been found large enough to 
admit the extremity of the little finger. These 
cells, when condensed by inflammation, form hard- 
ened masses in the substance of the tumour, which 
has a lardaceous appearance when cut, or resembles 
cartilage ; and they sometimes undergo conversion 
into bone. The testes are buried in the morbid 
mass towards its posterior part, but they are usually 
sound in structure. Occasionally there is a small 
quantity of serum in the tunica vaginalis. In a 
case operated on in Calcutta, there was a hydrocele 
on both sides imbedded in the diseased parts, the 
largest of which contained between five and six 
pints of fluid.* The spermatic cords are elongated 
several inches, owing to the testes being dragged 
downwards during the growth of the tumour, but 
they are not otherwise diseased. In a remarkable 
case operated on in Guy's Hospital, the cremaster 
muscles were nearly as thick as the finger.t The 
morbid growth is lowly organized. Its arteries 
are chiefly derived from the external pudic and 
perineal vessels ; but these, owing to the magnitude 
of the tumour, become of great size. The veins are 
numerous, large, varicose, and very tortuous. 

* Calcutta Quarterly Journal, No. 3. 
f Medical Gazette, vol. viii. p. 95. 
67 



530 ELEPHANTIASIS SCROTI. 

Elephantiasis chiefly affects the inhabitants of 
the warmer regions of the earth. It appears to be 
endemic in many parts of Asia and Africa, and is a 
very common disease in the East Indies, Syria, and 
Arabia, and also in Egypt. This disease was for- 
merly considered peculiar to Barbadoes ; but it now 
prevails in the other West India Islands, and like- 
wise on the continent of America. Negroes are 
very subject to it. It is not, however, confined to 
the natives of warm climates, though they more 
frequently suffer from its attacks than European 
residents. Very few cases of this disease have oc- 
curred in Europe. Sir W. Blizard presented to the 
College of Surgeons a good specimen of a scrotum 
and prepuce affected with this disease in its early 
stage, which appears to have been removed after 
death. M. Charles Delacroix, formerly minister for 
foreign affairs in France, suffered from this affec- 
tion of the scrotum for fourteen years. The tumour, 
which weighed thirty-two pounds, was removed by 
operation, and he afterwards recovered.^ Mr. 
Liston excised at Edinburgh a large tumour of 
this kind, which weighed upwards of forty-five 
pounds, from a young man aged twenty-two. It 
had commenced when he was only ten years of age, 
and had gone on increasing gradually from that 
time.t Delpech operated on a patient aged thirty- 
five, a native of Perpignan in the south of France, 

* Delonnes, Operation de Sarcocele. 

t Edinb. Medical and Surgical Journal, vol. xix. p. 566. This 
turaour is now deposited in the Museum of the College of Surgeons 
in London. 



ELEPHANTIASIS SCROTI. 531 

whose scrotum was converted into a large mass 
weighing sixty French pounds.* 

Elephantiasis of the scrotum is a morbid affection 
of the integuments, analogous to the enlargement 
of the extremities commonly known by the name of 
Barhadoes leg ; with which, indeed, in those coun- 
tries where the disease is prevalent, it is liable to 
be combined. Elephantiasis of the scrotum, how- 
ever, grows to a greater size and makes more rapid 
progress than the same disease in the leg, owing to 
the very loose texture and depending state of the 
parts. The labia pudendi of females in warm cli- 
mates are subject to a similar change, though not 
to the same extent nor so frequently as the scrotum. 

Elephantiasis has been attributed to inflammation 
of the lymphatic glands by Dr. Hendy, and of the 
lymphatic vessels by M. Alard. The inflammation 
of these parts, which is in general only temporary, 
is probably the effect rather than the cause of 
elephantiasis ; and in many cases in which there 
has been great enlargement the inguinal glands 
have been found quite free from disease. Dr. Wise, 
who appears to have seen a good deal of this disease 
amongst the natives of Bengal, believes that it is 
produced by an inflammation of the veins, and that 
it is a complaint analogous to phlegmasia dolcns.t 
Bouilland also inclines to the opinion that elephan- 
tiasis is caused by an affection of the venous system. 



* Chirurg. Clinique de Montpellier, t ii. p. 5. 

f Transactions of the Medical «,nd Physical Society of Calcutta, 
vol. vii. p. 156. 



532 ELEPHANTIASIS SCROTI. 

An obstruction of the lymphatics or veins can 
scarcely, however, be adequate to account for 
the remarkable hypertrophy or thickening of the 
cutaneous tissue, which occurs in this disease. 
We find, in cases of cancer affecting the axillary | 
glands and obstructing the course of the lymph- 
atics, that although great distension of the arm 
is produced by infiltration of the subcutaneous 
cellular tissue, it is not accompanied by a thickened 
state of the skin ; nor is this change the ordinary 
result of venous obstruction or of phlebitis. The dis- 
ease would appear to be something more than mere 
inflammation or obstruction, either of the lymphatic 
or venous system. 

Dr. Titley, who has published much interesting 
information on the subject of elephantiasis, states 
that we are totally unacquainted with the causes 
which give rise to it. In Barbadoes it was thought 
to depend on some local peculiarity ; but the disease 
having now extended throughout the other islands, 
in which the same local causes do not exist, at once 
negatives that supposition, and we must confess 
our ignorance of the circumstances on which it is 
dependent ; nor is it easy to account for the great 
frequency of the disease now in many islands in 
which it was forty or fifty years ago entirely un- 
known, and in which the climate, soil, customs, &c., 
were the same formerly as at present. He remarks, 
peculiarity of food or clothing, or exposure to the 
vicissitudes of the weather, cannot be considered to 
give rise to it ; for the children of the gentry, who 
are not exposed to these causes, are frequently af- 



ELEPHANTIASIS SCROTI. 533 

fected. It is not infectious, though he thinks that 
children born of parents labouring under the dis- 
ease are more liable to suffer from it than such as 
are descended from a more healthy stock."^ 

Symptoms, — Authors describe elephantiasis as 
commencing with rigors, followed by fever, pain, 
and heat in the part affected, and swelling and ten- 
derness of the neighbouring lymphatic glands, the 
scrotum remaining swollen after these symptoms 
subside. Similar attacks of fever and inflammation 
occur more or less frequently, and at various inter- 
vals, the tumefaction being increased after each 
attack. Dr. Titley states that on each accession 
of fever there takes place an effusion of lymph into 
the cellular membrane, and that the part affected 
remains swollen for a longer period after each at- 
tack. After several returns, the quantity of lymph 
effused being greater than can be absorbed, the 
limb or part becomes permanently enlarged. The 
skin, as the disease advances, becomes rough and 
rugged. Patients will live for many years, carry- 
ing about with them an enormous leg or scrotum, 
and will enjoy excellent health, except during the 
occasional attacks of fever. When the scrotum is 
the part affected, after a certain time the tumour 
increases, independently of the febrile attacks. 
Where the penis is also affected, these parts enlarge 
together in an equal ratio ; but if the scrotum only 
be affected, then the penis, as the scrotum enlarges, 
becomes drawn in, so as ultimately to disappear, 

* Dr. Titley on Diseases of the Genitals of the Male, p. 300. 



534 ELEPHANTIASIS SCROTI. 

and become completely imbedded in the tumour ; 
the prepuce being distended elongates, and opens 
by a navel-like aperture on some part of the an- 
terior surface (see figure, page 536), or even at 
the very end of the tumour.* 

When the disease is fully established the enlarge- 
ment increases gradually and constantly for many 
years, until at length the swelling reaches an 
enormous magnitude. As this takes place the skin 
is borrov^ed from the lower part of the abdomen, 
so that the hair on the pubes becomes thinly scat- 
tered on the front and upper part of the tumour, 
which at the same time encroaches on the perineum 
behind. The tumour, which is of an oval or py- 
ramidal form, the apex being superior, thus becomes 
attached to the body by a thick peduncle, which 
extends from the pubes, occupies the whole of the 
perineum, and terminates posteriorly at the verge 
of the anus. The surface of the swelling is some- 
times equal and smooth ; more generally it is rough, 
rugous, and tuberculated, and covered in various 
parts with brownish scales. It is often ulcerated 
in different places, the sores being covered with 
scabs, or discharging a sanious matter. The tumour 
feels firm and solid ; and sometimes, when handled, 
communicates an indistinct sense of fluctuation. 
In some instances it pits on pressure, but the den- 
sity and thickness of the skin usually prevent the 
part from receiving the impression of the finger. 
Its growth is unattended with pain ; the part is by 

* Lib. cit. p. 801, et. seq. 



ELEPHANTIASIS SCROTI. 535 

no means tender, and bears rough handling, and 
even being pricked and scratched without the pa- 
tient suffering uneasiness, owing to the skin having 
lost its natural sensibility. The chief inconvenience 
which it produces arises from its great bulk and 
weight ; occasioning deformity, impeding and in 
many instances entirely putting a stop to the pa- 
tient's movements, and interfering with micturition 
and the performance of the genital functions. 

Elephantiasis is sometimes complicated with 
scrotal hernia ; and often, as has already been ob- 
served, with hydrocele. There is scarcely any 
limit to the size which the tumour may attain. It 
has been known to acquire such a magnitude as to 
weigh more than two hundred pounds,* exceeding 
the weight of the rest of the body. Baron Larrey 
met with a case in Egypt in which the tumour was 
estimated to weigh fifty kilograms, or a hundred 
pounds ; and he also states that he saw, in different 
parts of the same country, ten or twelve more cases 
of the kind nearly as large. It has been found to 
measure more than four feet in circumference, and 
almost to reach the ground when the patient is in 
the upright position. In the case operated on by 
Clot-Bey, the morbid mass, which weighed one 
hundred and ten pounds, kept the patient's legs far 
apart, and obliged him to remain constantly on the 
ground ; it was so bulky that he could even sit upon 
it. In the accompanying figure of a black man 



* Case cited from " Ephemerides d'Allemagne," by Larrey, Me- 
moires de Chirurgie Militaire, t. ii. p. 115, 



536 



ELEPHANTIASIS SCROTI. 



affected with elephantiasis, taken from Dr. Titley's 
work, the tumour descended nearly to the ankles. 




All surgeons who have had much experience of 
this disease agree that it is entirely local, and tends 
but little to impair the general health and shorten 
the duration of life. The tumour, however, when 
of great size, is liable to mortify. Dr. Hendy of 
Barbadoes has related the case of a black man who 
had a scrotal swelling, which measured six feet in 
circumference, and twenty-four inches in length. 
A mortification of the part terminated the mise- 
rable existence of this poor creature.^ Dr. Hendy 



* A Vindication of the Facts and Opinions contained in a Treatise 
on the Glandular Disease of Barbadoes, p. 117. 



ELEPHANTIASIS SCROTI. 



537 



states that five other cases had come within his 
knowledge where the scrotum, being much enlarged, 
had sloughed, leaving the testicles denuded. 




[The above plate gives the appearance of a 
negro suffering from Elephantiasis Scroti, and the 
same individual two months after its extirpation by 
Dr. Picton of New Orleans. The operation was 
performed on the 3d of October, 1837, in the presence 

68 



538 ELEPHANTIASIS SCROTI. 

of twenty physicians and surgeons of New Orleans. 
The disease had existed ten years, and the weight 
of the tumour was fifty-three pounds. The prepa- 
ration is in the Anatomical Museum of the Uni- 
versity of Pennsylvania. — Am. Ed.] 

Diagnosis. — The symptoms of this disease are 
so remarkable, that it can scarcely be confounded 
v^ith any other affection. (Edema of the scrotum 
is the only disease which bears any resemblance to 
it. The rough and indurated state of the skin, 
the firm and solid nature of the tumour, and its 
large size, are characters quite sufiicient to pre- 
vent elephantiasis from being mistaken for simple 
oedema. 

Treatment. — Elephantiasis, when advanced so as 
to produce considerable enlargement of the scrotum, 
is an incurable disease. Various local applications 
and internal remedies have been tried, but there is 
no satisfactory account of beneficial effects having 
resulted. The surgeon rarely meets with this dis- 
ease at a sufficiently early period to afford a fair 
hope of his being able, by remedies, either to obtain 
its removal or even to arrest its progress. At its 
first commencement it should be treated by mild 
antiphlogistic remedies, the repeated application of 
leeches, and protracted counter-irritation ; the scro- 
tum being well supported, and the patient kept in 
the recumbent position. Iodine is a remedy which 
seems to be very applicable to this disease ; but I 
am not av^^are that it has yet been fairly tried in the 
early stage. Free scarifications and firm compres- 
sion long continued have been found of decided ser~ 
vice in reducing elephantiasis of the leg. Pressure. 



ELEPHANTIASIS SCROTI. 539 

however, cannot be applied with equal effect to 
the scrotum, owing to the want of some resisting 
point. 

When the enlargement of the scrotum has reached 
such a magnitude as to occasion serious inconve- 
nience and render the patient's life miserable, there 
is no other remedy but its removal by the knife ; an 
operation which has been performed in several in- 
stances with a favourable result. I have already 
noticed cases in which considerable tumours of the 
scrotum have been successfully removed by De- 
lonnes, Mr. Liston, and Delpech. Tumours even 
of a much larger size have also been excised, and 
the patients have afterwards recovered. Dr. Titley 
successfully removed from a young man, a negro, 
a tumour weighing seventy pounds, which is repre- 
sented in the engraving at page 536. Clot-Bey ex- 
cised one weighing one hundred and ten pounds.* 
There is nothing in the situation, structure, or re- 
lations of the tumour offering any objection to its 
removal. Its situation is external to the important 
cavities ; its structure is not very highly organized ; 
integuments are the parts affected ; and the only 
organs in any way involved are the testes and penis, 
— parts of importance, but not essential to life. But 
owing to the great extent of the parts divided, and 
the size of the vessels supplying a morbid mass of 
the magnitude which many of these tumours ac- 
quire, the operation becomes a very formidable and 
dangerous affair ; and patients have died from 
haemorrhage during or immediately after its per- 

* Histoire d'une Tumeur Elephaiitiaquo du Scroluni. 



540 ELEPHANTIASIS SCROTI. 

formance. In Mr. Listen's operation the flow of 
blood was compared by those present to the dis- 
charge of water from a shower-bath, it was so in- 
stantaneous and abundant. Before half the vessels 
could be tied the patient sunk off the table, without 
pulse and with relaxed muscles. He was only saved 
by being freely plied with strong whisky. Mr. Key 
removed, at Guy's Hospital, from Hoo Loo, a native 
of China, aged thirty-two, who came over to this 
country on purpose to undergo the operation, a 
tumour of the scrotum which w^eighed fifty-six 
pounds eight ounces ; but the patient died a few 
minutes after its termination from loss of blood.* 
A tumour weighing fifty-six pounds was excised by 
Dr. Goodeve of Calcutta ; but the patient, a man 
forty-five years of age, lost between thirty and forty 
ounces of blood, and gradually sank, and died in 
about six hours after the operation.! Dr. Titley 
has also recorded a remarkable case in which a 
mass weighing one hundred and sixty-five pounds, 
and measuring two feet five inches in length and 
five feet ten inches in circumference, was removed 
from a slave at St. Christopher by Mr. Wilks, a sur- 
geon. The operation occupied nearly eight hours ; 
a copious venous hemorrhage followed each stroke 
of the knife, and the man died, apparently from 
exhaustion, towards its conclusion.:): 

Before undertaking the removal of a large tumour 
produced by this disease, it is important to deter- 
mine whether the penis and testes can be preserved. 

* Medical Gazette, vol. viii. p. 93. 
t Calcutta Quarterly Journal, No. 3. 
I Diseases of the Genitals, p. 317. 



ELEPHANTIASIS SCROTI. 541 

Iq the operation expedition is of the greatest mo- 
ment ; and the patient's safety might be compro- 
mised by a tedious dissection in order to preserve 
those parts. Surgeons have commenced with the 
intention of leaving them ; but, in consequence of 
the alarming loss of blood, the attempt has been 
abandoned in the course of the operation. This 
was the case in Mr. Liston's operation, and like- 
wise in Mr. Key's ; the patient's powers, in the 
latter, having become so depressed, that Sir A. 
Cooper proposed that no further attempts should 
be made to save the penis and testes, which were 
accordingly excised. Clot-Bey and Dr. Titley suc- 
ceeded in saving the penis, but they were obliged 
to remove the testes. The elongation of the sper- 
matic cords, and the difficulty of finding healthy 
integuments to cover the genital organs, are fur- 
ther reasons for not making the attempt to preserve 
them when the elephantiasis is of great magnitude. 
Delpech succeeded, after a tedious and difficult dis- 
section, in saving these parts in his operation, which 
was performed in the following way. — Three flaps, 
two lateral and one in front, having been marked 
out on the tumour with ink, the operation was com- 
menced by the division of the integuments so as to 
form the flaps. Several vessels then required to 
be secured. An incision several inches in length 
was next made on the right side of the tumour; 
and, at the depth of two inches, a cluster of vessels 
was discovered proceeding towards the bottom of 
the scrotum. These, which were branches of the 
external pudic, were cut and tied near the groin. 
A similar incision was made on the left side, and 



542 ELEPHANTIASIS SCROTI. 

the corresponding vessels in like manner were 
divided and secured. Afterwards, on cutting 
deeper, the operator recognised the spermatic cord 
much enlarged. This was easily detached with the 
finger, which served as a guide for an incision 
through the whole depth of the tumour, in order to 
expose the testis, which was situated at a distance 
of a foot from the ring. This organ was enlarged 
without effusion in the tunica vaginalis, but it was 
rather firmly fixed at its posterior part to a kind of 
cavity in which it was lodged. The testis and cord, 
having been entirely disengaged, were deposited on 
the abdomen. A similar proceeding was pursued 
on the right side ; but with less difficulty, the testis 
not being so adherent. An attempt was next made 
to reach the penis by transverse incisions through 
the soft parts situated between the two rings ; but 
the great density of the tissues rendering this ha- 
zardous, the finger was introduced into the orifice 
at the bottom of the tumour through which the 
urine escaped, and the prepuce was divided upwards, 
the distance of a foot, as far as the penis. The in- 
cision was afterwards prolonged to the base of the 
organ and the symphysis pubis. The penis was 
carefully dissected out, and the prepuce cut away 
from around the base of the glans ; and the organ 
was then deposited, with the testes, on the abdomen. 
The peduncle of the tumour was detached with 
great care, in the course of which the different 
structures of the perineum were all exposed. The 
tumour having been at length entirely cut away, 
several arteries required to be secured ; including 
the artery of the septum scroti, the dorsal arteries 



ELEPHANTIASIS SCROTI. 543 

of the penis, the transverse artery of the perineum, 
the arteries of the bulb, and several branches of the 
inferior haemorrhoidal. All these vessels were tied 
separately, and the ligatures cut short. The testes 
were placed in the perineum at the sides of the 
penis ; but the spermatic cords, owing to their 
great length, being arranged in tortuous folds in 
order to occupy the limited space allotted to them, 
were with difficulty retained in their position. The 
two lateral flaps of integument were brought toge- 
ther, and their borders united by the interrupted 
suture, from the anus upwards, for four fifths of 
their extent. The anterior flap was then rolled 
round the penis, and united by suture, the anterior 
border being left free to form the prepuce ; and, in 
order to prevent the penis from slipping from its 
new sheath, a little of its cellular tissue was included 
in the sutures. The sides of this flap were then 
connected by suture to the remaining fifth of each 
lateral flap. The parts were afterwards supported 
and kept in contact by compresses of charpie and a ' 
double T bandage. The patient recovered, and the 
wound completely healed in two months. He re- 
turned to Perpignan, where he led an intemperate 
life, and died of a large abscess in the liver six 
months after the operation. 

The quantity of blood lost in this operation is 
not stated ; but we may infer that it was consider- 
able, for immediately afterwards the pulse was im- 
perceptible, the face pallid, and the limbs were 
cold. The tumour weighed sixty pounds ; and the 
time occupied in its removal, which, if we may 
judge from the minute details of the operation re- 



544 ELEPHAJNTIASIS SCROTI. 

lated by Delpech, was skilfully executed, was fifty- 
seven minutes, — a long period for the patient to be 
under the knife ; and the time subsequently taken 
up by the approximation of the flaps and dressing 
of the wounds of course greatly added to the dura- 
tion of the operation. Notwithstanding the re- 
covery of Delpech's patient, the case seems to me 
to afford but little encouragement to attempt the 
preservation of the genital organs in operations for 
the excision of tumours of so large a size. 

When no attempt is made to save the genital 
organs the operation is of a simple nature. The 
peduncle of the tumour is to be divided near its at- 
tachment to the body by rapid strokes made with 
a large bistoury, or a scalpel-shaped amputating 
knife, including in one sweep the penis and sper- 
matic cords, which latter should be immediately 
seized with the fingers by assistants to prevent 
their retracting. If any part of the integuments 
be sufiiciently sound to form a flap to cover the 
large open wound, the surgeon must take advan- 
tage of it, and modify the operation accordingly. 
When the intention is to preserve the genital 
organs, three flaps of appropriate size must be 
formed ; one in front to cover the penis, and two 
others, one on each side, to be brought together in 
order to invest the testes in the manner practised 
by Delpech. In cases complicated with hernia the 
sac is usually adherent to the diseased tissues 
around, and requires to be detached with caution, 
which tends to delay and increase the difficulties of 
the operation. Active assistants must be ready 
with their fingers to close the mouths of the bleed- 



HYPERTROPHY OF THE SCROTUM. o45 

ing vessels. Firm pressure on the cut surface by 
means of a large sponge, expertly applied so as to 
follow the surgeon's knife, will be found a good way 
of arresting the bleeding until the surgeon is ready 
to secure the vessels. Stimulants and the trans- 
fusing instruments should be at hand in case of 
need. It appears that patients who recover from 
the first effects of the operation generally do well, 
and that the large wound which is made heals 
readily. 



CHAPTER IX. 

HYPERTROPHY OF THE SCROTUM. 

The scrotum is liable to a hypertrophied affection 
of the same nature as the knotty and lobulated 
growth of the skin occasionally observed on the 
nose. In this affection the integuments appear as 
if composed of lobes divided by fissures. In the 
museum of St. Bartholomew's Hospital there is a 
preparation of this kind. It belonged to Mr. Aber- 
nethy ; but no history is attached to it. The 
hypertrophied scrotum appears to have been re- 
moved during life ; and I am informed by Mr. 
Paget that the sebaceous and hair follicles are 
remarkably developed in it. This disease is liable 
to be confounded with elephantiasis, but differs 
from it in the circumstance that the morbid en- 

69 



546 CANCER SCROTI. 

largement is entirely confined to the skin, the sub- 
cutaneous cellular tissue being unaffected. When 
the disease increases so as to cause inconvenience, 
it may be excised without difficulty or danger. 
I witnessed an operation in a case of this kind, 
which was performed by M. Velpeau at La Charite 
in Paris. The patient was a young man, whose 
scrotum w^as hypertrophied to about four times its 
natural size. He afterwards did well. 



CHAPTER X. 

CANCER SCROTI. 



Cancer scroti, or as it is commonly called chira- 
ney-sweepefs cancer, is a disease of the skin of 
a carcinomatous nature, which attacks the scrotum 
of persons who have been exposed to the contact of 
soot. It is originally developed in the form of a 
small pimple, or warty excrescence, termed soot- 
wart, which often remains on the scrotum for 
months, or even years, without undergoing any 
change. Usually there is only a single wart at the 
lower part of the scrotum ; sometimes there are two 
or three of different sizes ; and occasionally they 
are so numerous, and so abundantly and largely 
developed, as to form a considerable cauliflower ex- 
crescence. After a time the w^art becomes soft, 
excoriated, and red, and exudes a thin irritating 
discharge ; which, becoming dry, forms an incrus- 
tation over the excrescence. After the scab has 




CANCER SCROTI. 547 

been picked or rubbed off by friction against the 
dress, ulceration ensues, destroys the wart, and pro- 
duces a painful chronic sore, possessing the ordinary 
characters of a carcinomatous ulcer on the skin ; 
thick, indurated, and everted edges, and an irre- 
gular excavated base, the surface of which dis- 
charges a thin sanious fluid. The ulcer, if suffered 
to proceed, increases widely, in- 
vading the whole scrotum to the 
perineum, and laying bare the 
crura penis. At the same time 
it penetrates deeply to the tunica 
vaginalis, which becomes firmly 
connected to the morbid scrotum, 
and adherent to the testis. This 
organ, in time, also becomes in- 
volved in the disease, and forms the seat of a deep 
excavated sore. The glands in the groin often 
enlarge at an early period from irritation ; but at 
length these as well as the lumbar glands become 
indurated and diseased. The inguinal glands some- 
times suppurate, and form intractable ulcers in the 
groin, similar in character to the sore on the scro- 
tum. The ulcer spreads towards its circumference 
widely and superficially, whilst in the centre it 
burrows deeply, until in many instances it reaches 
the great vessels of the thigh, destroys their coats, 
and causes death by haemorrhage. In other cases 
the glands remain unaffected ; but ulceration con- 



O. 1. Small groot-warts. 

2. Cancerous nicer succeeding- the wart. — From a preparation 
in the London Hospital Museum. 



548 - CANCER SCROTI. 

tinues to proceed slowly in the direction of the 
cord, and in time extends to the groin and abdomen, 
its progress being attended throughout with severe 
darting pains. The patient's sufferings are pro- 
tracted for many months, and sometimes for years ; 
a frightful sore is produced ; he becomes gradually 
cachectic ; loses appetite and flesh ; his countenance 
assumes a peculiar leaden or waxy hue and anxious 
expression ; and he ultimately sinks, worn out by 
his sufferings and the effects of the disease on his 
constitution. 

The small excrescence in which cancer scroti 
usually originates is soft, vascular, and sensitive, 
and in many respects similar to the soft warts 
which occur on the internal membrane of the pre- 
puce, and on the glans penis. The soot-wart ap- 
pears, in fact, to consist of a congeries of morbidly 
enlarged papillae. The museum of the London 
Hospital contains a remarkable specimen of chim- 
ney-sweeper's cancer, in which nearly the whole scro- 
tum is occupied by a cauliflower excrescence, which 
exhibits these papillae in a very advanced state of 
developement. It was removed by Mr. Headington 
from an old man about sixty-four years of age, who 
afterwards left the hospital cured. Both testes 
were exposed in the operation. The morbid growth 
is composed of a number of projecting processes 
densely grouped together, of variable size, but many 
very large, with their summits lobulated, expanded, 
and elevated on narrow peduncles more or less 
flattened. Mr. Bagg has made an excellent repre- 
sentation of it in the annexed engraving. The 
warty processes closely resemble the elevated 



CANCER SCROTI. 



549 



growths abundantly developed about the cancerous 
ulcer, produced by soot on the back of the hand 
and wrist, preserved in the museum at St. Bartho- 
lomew's Hospital. The case will be described pre- 
sently. The soot-wart is sometimes covered with 
a dense and thick concretion, formed by successive 
layers of incrustation, the superficial still remaining 
attached, so as to form a projecting elongated conical 




process, which is not unlike the spur of the cock, 
and when very long is occasionally twisted like the 
horn of a ram. Some curious excrescences of this 
kind are represented in the clever etchings of Mr. 
Wadd."^ The figure on the next page, taken from 
one of them, exhibits the process of its exact size. 
Upon dissecting a scrotum affected with chimney- 
sweeper's cancer, the part is found to present very 
much the same appearances as carcinoma of the 
lip. The tissue at the base of the ulcer is dense, 

* Cases of Diseased Prepuce and Scrotum, PI. x. xi. xii. 



550 CANCER SCROTI. 

indurated, and distinctly laminated ; but it is not 
always easy to make out clearly any trace of hete- 
rologous deposit. The morbid structure possesses 
very little vascularity. On recently examining 
some matter scraped from the base of a soot-v^art 
shortly after its removal from the body, I distinctly 
perceived a number of caudate and spindle-shaped 
nucleated cells. Professor Walshe has likewise re- 




cognised the microscopical characters of cancer, in 
a specimen of carcinoma scroti examined imme- 
diately after excision.^ On examining some diseased 
glands in the groin, in a case of chimney-sweeper's 
cancer, I found them enlarged and indurated, and 
composed of a whitish brown or yellowish white 
substance, mixed up in some places with a soft curd- 

* Cyclopaedia of Practical Surgery, vol, i. p. 650. 



CANCER SCROTI. 551 

like matter, or grayish pus, contained in thin white 
cysts. 

Carcinoma scroti is, with few exceptions, confined 
to chimney-sweepers ; and the action of the soot 
on the skin of the scrotum is no doubt its exciting 
cause. That such is the case seems to be pretty 
clear, from the following interesting case, recorded 
by Sir James Earle. — Allan Spragg, aged forty- 
nine, came into St. Bartholomew's Hospital on 
account of a large cancerous sore, which reached 
from the bend of the wrist to the knuckles, occupy- 
ing almost the whole of the back of the left hand. 
He had been under the care of many persons, and 
various applications and internal remedies had been 
given. The circumference of the sore rose in large 
ulcerated tumours, and seemed inclined to spread. 
In some parts of the middle it appeared in a heal- 
ing state, in other parts ulcerated ; but he said dif- 
ferent parts of it had often healed, and broke out 
again, as we afterwards found it inclined to do. 
The complaint having very much the appearance of 
the sooty-wart, or chimney-sweeper's cancer, par- 
ticular inquiry was made into this person's life and 
occupation. He said he was a gardener ; that 
about five years before he was employed in a garden 
at Low Layton in Essex ; that in the spring of that 
year he was engaged about two hours every morn- 
ing to strew soot on the ground round the young 
and tender plants, to preserve them from the slugs ; 
that he carried the soot in an old garden-pot, which 
hung on the left hand by a handle over the top, 
while he strewed it with the right. About this 
time he conceived the wart commenced near the 



552 CANCER SCROTI. 

knuckles, and continued not very troublesome all 
that year. The next spring he was again employed 
to distribute soot : the wart was then increased and 
ulcerated, and continued growing worse all that 
year. The spring following he again used soot in 
the same manner : the sore then spread, and grew 
larger, which made work of any kind very difficult 
to him. For the last two years he had not used 
soot, but the sore continued to spread rapidly : 
however he kept on working till he was incapable 
of using the hand. Various means were used, both 
internally and externally, to cure the disease, but 
without any material service ; and at last he sub- 
mitted to amputation, after which the excruciating 
pains which he had suffered soon left him, the 
wound healed kindly, and he got perfectly well."^ 
From the appearance of the disease in this case on 
that part of the body where alone the soot was able 
to lodge, and its occurrence on the scrotum only 
in persons exposed to its contact, it is reason- 
able to conclude that this substance is the exciting 
cause of the disease.t 

This form of cancer, though occasionally deve- 
loped on the face, prepuce, glans penis, and other 
parts of the body of chimney-sweepers, occurs so 
much more frequently on the scrotum than else- 
where, that the term " chimney-sweeper's cancer'' is 
generally understood to imply a cancerous disease 
of the scrotum. The marked preference for this 

* Chirurgical Works of Percival Pott, by Sir James Earle, vol. iii. 
p. 182. 

f According to Dr. Ure, soot contains some sulphate and carbonate 
of ammonia, along with bituminous matter ; but it has not, that I am 
aware of, been very minutely analysed. 



CANCER SCROTI. 553 

part, in cases in which the skin of nearly the whole 
body is more or less exposed to the same source of 
irritation, is a circumstance worthy of notice. It is 
attributed to the scrotum being better adapted to 
harbour the soot than the integuments of any 
other region, the skin being loose and rugous, its 
sebaceous follicles large and numerous, and the 
part being usually moist and seldom cleansed. It 
would appear as if a lengthened contact of the soot 
was essential to excite the disease. In the case of 
the gardener just related, it was remarked that 
the right hand, which strewed the soot, was unaf- 
fected ; but the left, being two hours daily exposed 
to the vapours or dust arising from the soot as it 
was continually stirred up, a lodgment of it was 
probably made on the thin skin at the back of the 
hand. In the case of a very old man, whose face 
was wrinkled from age and therefore liable to retain 
the soot, mentioned by Sir A. Cooper, the sore was 
seated in the centre of the cheek.* 

Cancer scroti is known to be a rare complaint, 
even amongst the class of persons peculiarly liable 
to it, and many hundreds have followed the occu- 
pation of chimney-sweeping for years, and even 
during the whole of their lives, without contracting 
this disease. We must therefore conceive the ex- 
istence of individual predisposition as a condition 
necessary for its developement, and attribute a 
minor influence to the soot ; which, it would seem, 
does not generate the disease, but by its long-con- 

* Lib. cit. p. 227. 
70 



I 



554 CANCER SCROTI. 



tinued irritative action becomes the exciting cause 
of its production. Other irritating substances may 
excite a similar disease. Dr. Paris states that the 
smelters are occasionally affected with a cancerous 
disease in the scrotum, similar to that which affects 
chimney-sweepers.^ Dr. Warren of the United 
States remarks that he has met with a few in- 
stances of cancer scroti in persons who were not 
chimney-sweepers.t 

The predisposition to cancer scroti appears in 
some instances to be hereditary. The late Mr. 
Earle extirpated the testis and diseased integu- 
ments from a sweep aged 35, a patient in St. Bar^ 
tholomew's Hospital, whose grandfather, father, 
and one brother had all perished from the effects 
of the disease.^ A father and son were once in 
St. George's Hospital at the same time on account 
of it.§ Mr. Cusack mentions that he removed a 
soot-wart from the hand of a female who carried 
on the business of chimney-sweeping, and that he 
had previously excised an excrescence of the same 
nature from the ear of her son.|| 

Cancer scroti occurs more commonly at the 
middle period than at any other time of life. In 
the majority of cases which I have met with, the 
disease occurred between the ages of thirty and 
forty, and this accords with the experience of 
Mr. Earle.^ Those exposed, however, to the action 

* Pharmacolog-ia, vol. ii. p. 89. 

t Surgical Observations on Tumours, p. 328. | Lib. cit. p. 304. 
§ Mr. Hawkins' Lectures on Tumours, London Medical Gazette, 
vol. xxi. p. 842. 

11 Dublin Journal of Medical Science, vol. xxi. p. 137. 
IT Lib. cit. p. 299. 



CANCER SCROTI. 



555 



of soot may become affected at a much earlier 
period. Mr. Wadd has figured a diseased prepuce 
and soot- wart on the scrotum, from a boy aged 
fifteen ; and Sir J. Earle witnessed an undoubted 
case of the disease as early as at eight years 
of age. It is liable also to attack the scrotum of 
sweeps far advanced in life. The age at which 
cancer scroti usually first appears is a point of 
some interest. It appears that the seeds of this 
malady are sown in early life, but in general do 
not germinate until they have remained for some 
time dormant in the system. What is the per- 
manent effect on the scrotum produced by soot, 
which thus renders it in certain individuals so 
peculiarly susceptible of a cancerous action at some 
distant period, we cannot explain; but that the 
soot, though the exciting cause of the disease, may 
in some instances be a remote one, is shown by 
several striking facts. It is known that persons who 
have been sweeps when young, but have abandoned 
the occupation, have afterwards been attacked with 
chimney-sweeper's cancer, although they have long 
been removed from all contact with soot. — A sailor, 
between forty and fifty years of age, was admitted 
into the London Hospital with an ulcerated sore 
on the scrotum, presenting all the characters of 
genuine chimney-sweeper's cancer. The inguinal 
glands were indurated and enlarged. He had been 
brought up as a sweep ; but for the last twenty- 
two years, during which period he had served at 
sea, he had not been employed amongst soot in 
any way whatever. The disease first commenced 
on the scrotum about three years before. The 



556 CANCER SCROTI. 

diseased part of the scrotum was excised, but the 
man left the hospital before the wound was com- 
pletely cicatrized. In a few months ulceration 
commenced in both groins, and eight months after 
the operation he was re-admitted into the hospital 
with extensive ulcers in the inguinal regions, and 
in very impaired health, with a sallow complexion 
and much emaciated. About a fortnight after his 
admission, a considerable haemorrhage took place 
from the left groin, from the profunda artery (as 
was ascertained by dissection after death). Bleed- 
ing recurred at intervals, and in a week he died. 
In this case, therefore, the injurious influence of 
soot must have been exerted nineteen years before 
the appearance of disease, during which long period 
he was entirely removed from the effects of what 
is supposed to have been its exciting cause. It 
has sometimes happened, after the morbid parts 
have been completely extirpated, and the wound 
having healed the patient has avoided further 
contact with soot, that the disease has reappeared, 
as it were afresh, a second and even a third time ; 
not, however, in the cicatrix of the wound, but on 
a different part of the scrotum. These then, and 
similar facts, unfortunately lead to the conclusion 
that abandonment of his occupation, though it may 
render the adult chimney-sweeper less liable to 
cancer, by no means forms a satisfactory security 
against its occurrence. 

Cancer scroti chiefly extends its ravages by 
affecting the contiguous tissues, and has little dis- 
position to contaminate the lymphatic glands or 
distant parts. An instance is on record of an old 



CANCER SCROTI, 557 

chimney-sweeper, who had been subject to this 
disease for forty years, and had undergone three 
operations for its removal, yet even then the glands 
in the groin were unaffected.^ In a case also of a 
chimney-sweeper who had been repeatedly attacked 
with this disease during more than twenty years, 
and had submitted to no less than five operations 
for its removal, which I have related at page 561, 
it was only recently that the glands in one groin 
became affected. The inguinal glands are fre- 
quently enlarged from irritation, but the swelling 
generally subsides after removal of the morbid 
parts. It must not be supposed, however, that 
these glands constantly escape carcinomatous inva- 
sion. I have myself witnessed three instances, in 
which they were enlarged and indurated, and after- 
wards suppurated and became the seat of a true 
cancerous ulcer ; and similar cases have occurred 
in the practice of other surgeons. 

Chimney-sweeper's cancer is a disease almost 
peculiar to this country. Dr. Warren, a surgeon 
of great experience in the United States, remarks 
that he has never seen it in chimney-sweepers in his 
country.t RicherandJ and other French writers 
inform us that it does not occur in France. Pit- 
coal, from which soot is produced, is very sparingly 
employed as fuel abroad ; whilst in this country its 
almost universal use by all classes, and the inhuman 
custom of employing climbing-boys to cleanse our 
chimneys, only very recently abolished, are sufficient 
to account for the occasional occurrence of this pe- 

* Mr. Hawkins' Lectures on Tumours, lib. cit. 

t Loc. cit. I Nosog-raphie Chirurgicale, torn. iv. p. 300. 



558 CANCER SCROTI. 

culiar disease. But chimney-sweeper's cancer is by 
no means a common affection even in Great Britain. 
Mr. Russell states that it is rare at the Royal In- 
firmary in Edinburgh, and that he has seen but 
few cases of it."^ Mr. Syme makes a similar state- 
ment. Within my own recollection the complaint 
has become much less common than formerly in 
the large Hospitals of London, which I believe to 
be owing to the general use of machinery in the 
cleansing of chimneys during the last few years. 
The legislative enactment to prevent the employ- 
ment of climbing-boys for this purpose, which has 
lately come into operation, we may fairly expect 
will in the course of a few years, render the dis- 
ease even far more rare than it is now. It will 
not have the effect, as som.e have hoped, of com- 
pletely removing this description of cancer from the 
list of human maladies ; for master-sweeps, unless 
very cleanly in their habits, will still be liable to it ; 
but as a cause of mortality its influence will be 
very materially reduced. 

Diagnosis. — I scarcely know of any disease for 
which chimney-sweeper's cancer in a state of ulcer- 
ation could well be mistaken, the malignant cha- 
racter of the sore having been in all cases that I 
have witnessed very clearly marked. The warty 
excrescence which precedes the ulcerative stage 
bears some resemblance to the syphilitic warts 
which sometimes form on the scrotum ; but the 
history of the case, and more especially the occupa- 
tion of the patient, would always excite suspicion, 

* Observations on the Testicle, p. 98. 



CANCER SCROTI. 559 

and in most instances be sufficient to indicate the 
true nature of the disease. 

Treatment. — Cancer scroti is a disease quite be- 
yond the control of topical and internal remedies. 
Time has been lost in attempts to eradicate it by 
arsenical and various other escharotic applications, 
but nothing hitherto tried has proved of any avail 
in arresting its destructive progress. There is, 
indeed, no remedy but the knife ; and fortunately 
this is a resource attended w^ith a greater share of 
success than generally awaits operations on can- 
cerous disease in other parts. When the scrotum 
is alone affected, the proceeding is very simple. 
The morbid parts are to be removed by two ellip- 
tical incisions, care being taken to cut wide of all 
disease ; for if any part of the morbid tissue be left 
behind, the complaint will certainly reappear. If 
the base of the ulcer be adherent to the tunica 
vaginalis, so that the morbid parts cannot well be 
removed without excising a portion of that mem- 
brane, the surgeon, instead of attempting to save 
the testis, should at once perform castration. The 
disease indeed has not much tendency to spread 
to the testes, and it often makes extensive ravages 
in the parts around without reaching them ; but 
in a complaint of so fatal a nature, it is better 
to err on the safe side by removing more than is 
absolutely required, than incur any risk of a re- 
turn of the disease. When the testis even is ulcer- 
ated, it is now admitted, contrary to the opinion 
entertained by Mr. Pott, that an operation may be 
undertaken with a fair prospect of a successful 
result. 



569 CANCER SCROTI. 

The inguinal glands are so seldom contaminated, 
till a late period of the disease, and the swelling 
to which they are liable in this affection is so 
rarely of a specific character, that, as a practical 
rale, simple enlargement of them does not con- 
stitute an obstacle to the excision of the diseased 
scrotum. If they should be much indurated as 
well as enlarged, and the seat of lancinating pains, 
there would be sufficient reason to apprehend that 
the disease had extended to them ; but unless de- 
cidedly carcinomatous, I should be inclined to afford 
the patient the chance of relief from so terrible a 
malady as cancer by an operation which in itself 
is neither severe nor hazardous. A case has been 
published^ in which, after excision of the diseased 
part of the scrotum, several indurated glands in 
the groin which were the seat of lancinating pains 
were carefully dissected out by the eminent surgeon 
who operated. I do not know what was the ulti- 
mate result of this case, but I should scarcely an- 
ticipate success from such a proceeding. If the 
glands were merely enlarged from irritation, their 
extirpation would of course be unnecessary ; but 
when affected with carcinomatous deposit, I should 
fear that the disease had become too deeply rooted 
to admit of being wholly and successfully removed 
by operation. 

After chimney-sweeper's cancer has to all ap- 
pearance been effectually extirpated, and the wound 
has healed and remained so for some length of time, 
the disease has often been known to reappear ; and, 

* Lancet, 1840-1, p. 793. 



CANCER SCROTI. 661 

what is remarkable, it does not in general return 
in or near the cicatrix of the wound, as ordinarily 
occurs after operations for cancer in other situations, 
but is often developed in a different part of the 
scrotum. Now I believe that in these cases the re- 
appearance of the disease is not in general the result 
of previous contamination, or of imperfect removal 
of the morbid tissues, but that the cancer is gene- 
rated altogether anew. The eifect of the operation 
would seem to be the eradication of all existing dis- 
ease, but unfortunately not to destroy the inherent 
susceptibility to its developeraent in the parts that 
remain ; which may subsequently, therefore, become 
a fresh seat of cancerous action, especially if, as 
often happens, they continue exposed to its exciting 
cause, the soot. The surgeon should not, then, 
exactly apply to these cases the principles which 
regulate his conduct in treating cancer in other 
parts, in which a repetition of the operation is 
generally inadmissible, and rarely successful. On 
the contrary, if cancer appear after extirpation in a 
fresh part of the scrotum, it must be met as if it 
were a new disease, and not the return of an old 
one ; and a second operation may be undertaken on 
the same grounds, and nearly with the same hope 
of success, as in the first instance. I have heard, 
indeed, of two interesting examples in which life 
had evidently been prolonged by a second and third 
operation ; and of another instance in which after 
the performance of a second operation the patient 
lived for years, and ultimately died of another dis- 
ease. The following case, which has recently come 

71 



562 CANCER SCROTI. 

under my notice, likewise illustrates the above views 
of this disease. — William More, aged fifty-one, a 
man of stunted growth, who had been a chimney- 
sweeper since the age of seven years and still fol- 
lowed the occupation, applied to me April 27, 1843, 
on account of a painful swelling in the groin. It 
appeared that he had been affected with chimney- 
sweeper's cancer for many years. As long ago as 
the year 1821, a portion of his scrotum affected 
with this disease had been excised at St. Bartholo- 
mew's Hospital ; and he had since undergone two 
operations of the same kind in that hospital, in 
consequence of a return of the cancer. Another 
part of the scrotum was afterwards removed at 
Guy's Hospital ; and in March last a portion of 
integument at the under part of the penis was ex- 
cised by a surgeon in the city, — making in all five 
operations. The scrotum was much contracted, 
and marked by several cicatrices. The scar under 
the penis, which was still sore, was separated from 
the scrotum by some sound skin. There was a 
tumour in the groin, which was soft in the centre and 
fluctuated, but had a very indurated base ; and the 
man complained of experiencing pricking and shoot- 
ing pains in it. This swelling in the groin, which 
was obviously of a carcinomatous character, had 
only appeared since Christmas last, though he had 
been subject to the disease in the scrotum for two 
and twenty years. 

When the inguinal glands are ulcerated, or the 
cancerous disease has extended too far to admit of 
its being effectually extirpated, there is nothing to 
be done but to endeavour to mitigate the patient's 



MELANOSIS OF THE SCROTUM. 563 

sufferings by opiates and anodyne applications, and 
to correct the irritating fetid discharge. Henbane 
and the acetate or muriate of morphia may be 
given internally, and a lotion containing the chloride 
of lime and tincture of opium applied to the sore; 
or it may be covered with a poultice composed of 
an ounce of the dried leaves of conium, three ounces 
of bread, twelve ounces of water, and a small 
quantity of the chloride of lime. 



CHAPTER XL 

MELANOSIS OF THE SCROTUM. 

I HAVE not met with any account of melanosis 
occurring in the scrotum ; but the following case 
appeared to be an instance of it. — A cabinet- 
maker in the Commercial Road, aged thirty-two, 
and enjoying tolerable health, consulted me in 
November, 1842, on account of a fungous growth 
on the scrotum. The tumour was about the size 
of a small walnut and of a dark colour, had an 
irregular granular surface, and was attached to the 
left side of the scrotum by a narrow peduncle or 
neck. About an inch on one side of this tumour I 
observed a small dark spot, apparently produced 
by some black deposit beneath the epidermis raising 
it a little above the surrounding surface. The 
patient stated that the fungous growth was first 
noticed about three months before, when it resem- 



564 ADIPOSE TUMOURS OF THE SCROTUM. 

bled the little speck just described, which had only 
been observed a fortnight. It had increased 
rapidly of late, but gave no pain. The shirt was 
discoloured by a slight discharge and bloody marks. 
There was no enlargement of the glands in the 
groins. I excised the tumour and small speck near 
it. On making a section of the morbid growth, 
the fungus appeared to spring from the cutis. Its 
base was hard and evidently fibrous, and of a 
schirrous character ; but the projecting part was 
soft and easily broken down. Small irregular 
spots of melanic pigment were observed on the cut 
surface, as well as on the exterior of the tumour, 
and the little speck seemed to consist of a similar 
matter deposited immediately beneath the epider- 
mis. The morbid growth is preserved in the Lon- 
don Hospital museum. The wound healed favour- 
ably, and as yet there is no appearance of a return 
of the disease. 



CHAPTER XII. 

ADIPOSE TUMOURS OF THE SCROTUM. 

Collections of fat in the scrotum have been 
known from the time of Galen by the term " Stea- 
tocele." Morgagni states that he has sometimes 
seen fat accumulated in the scrotum to a consider- 
able extent.* I am indebted to Mr. Kiernan for a 

* Cook's Morgagni, vol. ii. p. 435. 



FIBROUS TUxMOURS OF THE SCROTUM. 565 

section of a large scrotal tumour entirely composed 
of adipose tissue in the lobulated form. As the 
cellular tissue of the scrotum naturally never con- 
tains fat, the latter, when present in any quantity, 
must be regarded as an adventitious formation. 
Such tumours, however, are of exceedingly rare 
occurrence. 



CHAPTER XIII. 

FIBROUS TUMOURS OF THE SCROTUM. - 

A SMALL fibrous tumour has in some few instances 
been developed in the cellular tissue of the scrotum. 
It may acquire the size of the testis, and, being 
firm and of an oval form, resemble a supernume- 
rary gland. At page 75, 1 have described a tumour 
of this kind, which was removed from the scrotum 
by Professor Fergusson. 

Dr. Mott, of the United States, excised an enor- 
mous diseased mass from the scrotum of a man 
about seventy-three years of age. The scrotum 
was twelve to fifteen times its ordinary bulk, and 
was filled with tumours of a stony hardness, from 
the size of nutmegs to that of a large pea. The 
tumours had all a very white appearance ; and the 
integuments over two or three of the largest, hav- 
ing been ulcerated for upwards of a year, poured 
forth a fetid discharge. A white substance, re- 
sembling mortar, was discharged from these open- 



566 FIBROUS TUMOURS OF THE SCROTUM. 

ings. The disease was upwards of twenty years 
duration, and had been gradually increasing, the 
tumours multiplying as the scrotum augmented in 
size. The whole of the disease was removed, and 
the patient recovered from the operation, and at 
the end of three years afterwards he was enjoying 
excellent health.* I suspect this disease was 
originally a fibrous tumour similar to the small one 
which I have described as having been removed 
from the scrotum by operation. The calcareous 
matter and other changes resemble those occasion- 
ally observed in large fibrous tumours of the uterus. 

* Philadelphia Journal, as quoted in the Ix)ndon Medical and 
Physical Journal, vol. Iviii. p. 516. 



APPENDIX. 



After Chapter IV., Section 3, which contains an 
account of encysted hydrocele of the testis, had 
passed through the press, I was informed by Mr. 
Liston that on recently examining some rather 
milky-looking fluid removed by operation in a case 
of this affection, he had discovered myriads of sper- 
matozoa ia it in a lively state, and he has favoured 
me with a view of some of them which were pre- 
served. Mr. L. thinks that this interesting fact 
may indicate the mode of developement of encysted 
hydrocele ; and if further observation should prove 
that the cyst originates in a dilatation of one of the 
tubes of the epididymis, that the mucous character 
of the sac would explain the difficulty which exists 
in procuring their obliteration by injection. Ac- 
cording, then, to this supposition, encysted hydro- 
cele of the testis very much resembles, in its mode 
of developement, the swelling formed by a dilatation 
of the duct of the submaxillary gland termed raniila ; 
but as this view is opposed to that which I have 
been led to take of the origin of this affection, I 



568 APPENDIX. 

availed myself of an early opportunity of carefully 
examining, in several recent testes, the small serous 
cysts w^hich are so commonly developed in the head 
of the epidid}/mis ; and in which 1 concluded, after 
numerous dissections, that this form of hydrocele 
commonly originates. (See page 214.) I can now 
state that I have found no reason to question the 
accuracy of this explanation. In the testis with a 
single cyst at the head of the epididymis, removed 
from a man aged twenty-one, who died of fever, 
abundance of spermatozoa were observed in the 
contents of the epididymis, but none could be 
detected in the clear pellucid fluid of the cyst. The 
cyst was distinctly seen to be unconnected with the 
seminal ducts; and on examination in the micro- 
scope its internal surface exhibited the characters of 
a serous membrane. I am inclined, therefore, to 
believe that the occurrence of spermatozoa in Mr. 
Liston's case was accidental, owing probably to the 
rupture of the seminal canal, which permitted an 
escape of the spermatic fluid. 



THE END. 



3477 
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